Report and recommendations

ADOLESCENT SUICIDE TASK FORCE
REPORT and RECOMMENDATIONS
THE GOVERNOR'S OFFICE FOR CHILDREN
Fife Symington, Governor
Lynne N. Gallagher, Director
Eric Benjamin, M.D., Chair
Janet M. Wise, Project Coordinator
May, 1994
With special thanks to Robert Schackner of the Child Fatality Review Program,
Arizona Department of Health Services
THE ADOLESCENT SUICIDE TASK FORCE
Cheryl Collier Becker
Mental Health Association of Maricopa County
Phoenix
Eric Benjamin, M.D., Chair
Phoenix Children's Hospital
Phoenix
Ilene Dode, Ph.D.
Empact Suicide Prevention Center
Tempe
Roger Griggs
White Mountain Apache Tribe
Whiteriver
Steven Kalas
Empact Suicide Prevention Center
Tempe
Jettie McWilliams, Ed.D.
Northern Arizona University
Phoenix
Arlene Metha, Ph.D.
Arizona State University
Tempe
Michelle Moorhead
Teen LifeLine
Phoenix
iii
Barbara Olson
Arizona Department of Health Services
Phoenix
Joel Sadowsky
Dances with Opportunities
Tucson
Robert Schackner
Arizona Department of Health Services
Phoenix
Sandra Sperry
Peoria Unified School District
Peoria
Vicky Stromee
Help on Call
Tucson
Margaret Walker
White Mountain Apache Tribe
Whiteriver
Tom Welter
Welter, Incorporated
Mesa
Janet M. Wise
Governor's Office for Children
TABLE OF CONTENTS
Executive Summary .......................................................................... ix
Introduction and Background .............................................................. 1
Psychiatric Diagnoses and Risk Factors Subcommittee Report ........................... 11
School-Based Prevention Programs Subcommittee Report ............................... 25
Community-Based Programs Subcommittee Report ...................................... 31
Appendix A: Crisis Intervention Procedures ........................................ 35
EXECUTIVE SUMMARY
by Eric Benjamin, M.D.
The first question I asked the members of the Adolescent Suicide Task Force upon becoming
chairman was, "Must one have a psychiatric disorder in order to experience a suicidal episode?" A
suicidal episode is defined as an occurrence of suicidal ideation, threats, attempts, completion or any
combination of these factors. After much research and debate, the members concluded that, indeed,
almost all suicidal individuals have a psychiatric disorder as defined in the Diagnostic and Statistical
Manual of Mental Disorders, third edition, revised (DSM-111-R).
We found that those at risk for suicide had depressive disorders, or other mood disorders, impulse
control disorders such as Attention Deficit Hyperactivity Disorder (ADHD), and frequently a family
history of suicide or previous suicidal episodes. In addition, substance abuse or alcoholism further
enhanced the risk. The access to a lethal method, particularly firearms, increased the likelihood of a
completed suicide.
Not all young people with these psychiatric disorders commit suicide. Psychiatrically disordered
children and adolescents are at greater risk if they are from disrupted families with lower levels of
education, low economic status, or if they are raised in environments where they are chronically
exposed to abuse, violence or criminal activity.
Therefore our recommendations follow from these well-researched findings:
1. Those children whose biological parents or relatives have a family history of previous
suicidal episodes must be screened and monitored as part of their early health care.
This is a genetically at-risk population of children who are vulnerable to suicidal
behavior. These children must have universal access to mental health care from the
time behavioral problems are first noted (i.e., in school, by parents, by a pediatrician,
etc.). Timely treatment of this population will serve to prevent the morbidity and
mortality that is associated with suicidal episodes.
2. Children and youth with depressive disorders and other mood disorders, impulse
control disorders (ADHD) and drug or alcohol problems must also have universal
access to mental health services. Again, a family history for these disorders increases
the risk that these children will have similar problems through inheritance.
3. The availability of firearms to children and youth predisposes this vulnerable
population to a greater rate of suicide completion. Thus, there should be stringent
control of the availability of firearms to children and adolescents. When there is a
family history of suicidal episodes or the psychiatric disorders described above,
specific safeguards should be in place if firearms are to be present in the home.
We strongly urge legislators and the general public to understand that suicide and homicide are two
indicators of the status of mental health of our children and adolescents. Both of these behaviors are
the outcomes of psychiatrically disturbed youth having access to lethal means where there are few
social supports or treatments in place. Indeed, homicidal or aggressive behavior is the outward
display of poor impulse control and mood disorders, often in combination with alcohol and drug
problems, learning disorders or other psychiatric disorders. Identification of this at-risk population
as described above, with early treatment, will prevent the morbidity and mortality for both the
individual and society. This will be reflected not only in lives saved, but in monetary savings as well.
As we approach the twenty-first century, Prevention should become the treatment approach for these
psychiatrically disordered children as early as possible in life. Thus, a three-year-old exhibiting
impulse control problems in a chaotic home environment where homicidal or suicidal behavior has
occurred in the parents or relatives requires immediate access to long-term mental health care. The
price tag of identifying and treating this child, when compared to the cost of paying for his
habilitation as an adult is minimal, particularly when one considers that he may contribute to society
in a productive manner if treated.
The Adolescent Suicide Task Force has explored various programs, both at school and in the
community, including school-based prevention programs and crisis hotlines to identify children and
adolescents at risk. We have also detailed paradigms to be implemented to help in this task.
Ultimately, the funding of the programs designed to triage and initiate treatment of these youths, at
school and in the community, and the funding of the mental health care delivery system to assess and
maintain treatment will provide the means to prevent suicide, homicide, and other aggressive
behavioral disorders in children, adolescents and adults. The return on this investment will be a safer,
healthier world at less cost to society.
INTRODUCTION
The Adolescent Suicide Task Force, organized in November, 1991, is an outgrowth of the State Select
Commission on Adolescent Suicide that was originally convened in September, 1988. This
Commission produced a Prevention Program Guide and submitted a Report of its activities to the
Governor in September, 1989. This Report recommended increased funding for behavioral health
services and coordination among state agencies to reduce fragmentation and maximize resources.
In spite of these efforts, the problem of suicide among teenagers and young adults in Arizona has
remained serious. When Marti Lavis assumed the Directorship of the Governor's Office for Children
in April, 1991, several members of the State Select Commission asked her to organize a group to
study the problem and develop new strategies for decreasing suicides among Arizona's most
important resource, its youth.
Dr. Eric Benjamin, Medical Director of Child and Adolescent Psychiatry at Phoenix Children's
Hospital, was named Chair in March, 1992, and has provided able leadership since that time. Under
his direction, the Task Force conducted a review of the substantial literature that exists on the subject
of teen suicide and divided into three subcommittees to study specific aspects of the issue. These
subcommittees included:
Psychiatric Diagnoses and Risk Factors
School-based Prevention Programs
Hotlines, Crisis Intervention and other Community Programs
The following report is the result of two years' work on the part of the Task Force and its
subcommittees. Although the Task Force has experienced many challenges during this period, it
has continued to work toward a greater understanding of the problem and identification of realistic
strategies to improve outcomes.
But recommendations, no matter how well researched or articulated, are empty words without the
will to translate them into reality. The ultimate success of the Task Force will depend upon its mes-sage
being heard and addressed across the state in homes, schools, mental health centers and among
those who set priorities and make decisions at the state level.
Teen suicide cannot be seen in isolation. Often the culmination of failed hopes, nonexistent
opportunities and unmet mental health needs, it is exacerbated by the conditions facing young people
today. These include poverty, broken families, substance abuse and rapidly escalating violence. It is
critical that we as a state begin to address these primary issues if the condition of our children and
youth is ever to improve.
BACKGROUND
DEFINITIONS AND RISK FACTORS
Suicidal Ideation - Persistent thoughts or ideas about killing oneself.
Suicidal Threat - Involves thoughts about killing oneself as well as overt expression of these thoughts.
Suicide Attempt - A self-inflicted act with the intent to cause injury.
Suicidal Episode - An occurrence of suicidal ideation, threats, attempts, completion or any
combination of these factors.
Psychiatric Disorders - Conditions described in the Diagnostic and Statistical Manual of Mental
Disorders (Third Edition - Revised).
Adolescence - The period of physical and psychological development from the onset of puberty to
maturity. Exact age markers cannot be assigned to this transition because individuals enter and leave
it at different ages. Usually, however, adolescence takes place between the ages of 10 and 24. Within
this transitional period, there are several developmental tasks to be completed:
Transition from dependence on family to independence.
o Development of identity and sense of social responsibility.
Development of mature personal relationships including sexual relationships.
Identification of career goals and acquisition of skills necessary for economic
independence.
Risk Factors Associated with Adolescent Suicidal Episodes - See the second section of this report
for a more complete description of these factors.
Previous suicide attempts.
Suicidal ideation.
Family history of suicidal episodes.
Psychiatric disorders.
Depression and hopelessness.
Poor impulse control.
Substance abuse and/or alcoholism
Stressful life events and humiliating experiences.
Disturbed interpersonal relationships.
Gender identity issues.
Accessibility of firearms.
Prominent display of suicide in the media.
ADOLESCENT SUICIDE IN ARIZONA
Throughout the decade of the 1980s and the early 1990s, the suicide rate in Arizona has been among
the highest in the nation. This is true for persons of all ages as well as for adolescents. From 1985
through 1989, Arizona's rate of suicide for persons of all ages ranked among the five worst while its
average rate for persons between 15 - 24 ranked eighth (Mrela, 1991). Mrela stated that, "The 1991
Arizona suicide rate was 50.9 percent higher than the national rate, and 58.1 percent higher than the
year 2000 national health objective of 10.5 suicides/100,000 population." (1991, p. 4) Table 1
provides comparisons of suicide rates and numbers over a ten year period for three age groups.
TABLE 1
NUMBER OF SUICIDES AND SUICIDE RATES 1982 - 1992
Other states with high rates of suicide are, with few exceptions, Rocky Mountain States (Centers for
Disease Control and Prevention, 1993). Figure 1 shows the states with the highest and lowest suicide
rates for individuals between 10 and 24 years of ages for the years 1987 and 1988. Although there
has been considerable speculation about the cluster of high rates in the West, a definitive answer does
not appear to be available. Possible explanations include isolation, transient populations and higher
rates among Native Americans. Although each of these has merit, none seems to hold true for all the
states involved.
In Arizona, the theory of transiency is not consistent with other trends. Teenagers in urban environ-ments,
where transiency is greatest, were not killing themselves with the same frequency as rural
youths. From 1980 to 1989, the increase in teen suicide rates was 3.4 times greater for rural teens
(Gersten & Mrela, 1990). In 1991, the counties with the highest suicide rates for persons 15 - 24 were
rural counties with the highest rates of all seen in Apache, Cochise, Pinal and Yavapai (Mrela, 1993).
The suicide rate for individuals 15 through 19 years of age has increased steadily between 1981 and
1991 while the rate for persons 20 - 24 has declined slightly (Mrela, 1993). Figure 2 illustrates the
trend toward increasing rates among teenagers.
Although the number of suicide attempts is believed to be much greater among females, the number
of completions is considerably higher among males. In 1991, There were 40 deaths by suicide
among males 15-19 years of age and 9 among females in the same age group. In the young adult
age group, 20 - 24, a similar difference was evident. In 1991, there were 52 males who killed
themselves and 10 females (Mrela, 1993).
The highest suicide rates for Arizona youth are among white males and Native American males. The
rate for Native Americans teens of both sexes was especially high in 1990 (40.2 deaths per 100,000
population). This rate was more than twice the rate for white teenagers (18.7) and almost nine times
the rate for hispanics (4.6) (Mrela, 1992).
According to the American Association of Suicidology (1993), the most common method of suicide
is use of firearms. Nationally, 61.1 % of the suicides for persons of all ages in 1990 were the result of
firearms. The second most common method in 1990 was hanging, strangulation or suffocation
which accounted for 14.4% of all suicides. This was followed by ingestion of solid or liquid poisons
which accounted for 10.2% of all deaths by suicide.
A somewhat different mix of methods is observed in attempted suicide. Most common is the
overdose of medication, often in combination with other substances. Attempts also involve jumping
from high places, use of cutting instruments such as knives and razors as well as hanging, gassing and
traffic accidents.
In Arizona, firearms accounted for 67.6 % of all suicides from 1989 to 1991. Most of the increase in
suicides among young people can be accounted for by use of firearms.
It seems likely that actual attempts and completions are significantly more numerous than reported
figures indicate. Many suicidal episodes and actual attempts are never reported. Also, it is frequently
difficult to determine whether certain fatalities are planned or accidental, especially those involving
motor vehicles. For this reason, the Task Force has chosen to emphasize suicidal episodes rather than
completions.
FIGURE 3
STATES WITH THE HIGHEST AND LOWEST RATES OF SUICIDE
for
PERSONS 10 - 24 YEARS OF AGE, 1987 - 1988
Hawm~
Highest death rates Lowest death rates
Source: Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death
and Related Risk Behaviors among U. S. Adolescents. p. 33.
FIGURE 2
Source: Mrela, C. K. (1994). Arizona Department of Health Services
8
SUICIDE MORTALITY AMONG ARIZONA'S
ADOLESCENTS 15-1 9 YEARS OLD BY YEAR FROM
1982 TO 1992 AND COMPARISON WITH YEAR 2000
HEALTH OBJECTIVE
22 -
Number of suicide deaths per lD0,DDD
adolescent8 15- 1 9 years old:
19--
16--
10
x--x--x--*--x-
I I I I I I I I I
1982 1983 1984 1985 1986 1987 1988' 1989 1990 1991 1992
YEAR
Note: the fltraight line is the trend line calculated by a least-square approximation method
known also as a simple linear regression.
REFERENCES
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders:
(3rd. ed., Revised). Washington, D. C.: Author.
Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death and Related
Risk Behaviurs Among U. S. Adolescents. Atlanta: Author.
Gersten, J. C. & Mrela, C. K. (1990). Closing the Decade: Arizona Health Status and Vital
Statistics, 1980 - 1989. Phoenix: Arizona Department of Health Services.
McIntosh, J. L. (1993). Methods of Suicide. Denver: American Association of Suicidology.
Mrela, C. K. (1991). Suicide Mortality: Arizona, 1980 - 1989. Phoenix: Arizona Department of
Health Services.
Mrela, C. K. (1992). Suicide h4ortality: Arizona, 1990. Phoenix: Arizona Department of Health
Services.
Mrela, C. K. (1993). Suicide Mortality: Arizana, 1991. Phoenix: Arizona Department of Health
Services.
Mrela, C.K. (1994). Pattms ofMortality by Ethnic Group. Phoenix: Arizona Department of Health
Services.
PSYCHIATRIC DIAGNOSES AND RISK FACTORS
SUBCOMMITTEE
REPORT and RECOMMENDATIONS
ADOLESCENT SUICIDE RISK AND PREVENTION
Dramatic demographic and social changes occurring during the latter half of the twentieth century in
the United States have contributed to social and personal disorganization. Demographic changes
include urbanization, population mobility and increasing numbers of poor, uneducated, unemployed
and disadvantaged members of society. Social factors include the decline in religious/moral values,
prevalence of divorce and the startling increase in the number of single-parent families. Earlier
initiation of sexual activity, increased unintentional pregnancies, sexually transmitted diseases, child
abuse, domestic violence, increased criminal activity all tend to exacerbate the situation.
Stigmatization surrounding gender identity conflicts is an additional factor.
These societal stressors appear to be associated with feelings of anger, alienation and hopelessness
among vulnerable individuals, including adolescents. When associated with psychiatric illness,
especially depression, individuals may experience loss of self-esteem, decreased coping skills and a
loss of hope. Trigger factors such as the use of alcohol or drugs, the availability of a lethal method
(particularly firearms) and the occurrence of stressful life events may increase the likelihood of a
suicidal episode.
Risk Factors for Adolescent Suicidal Episodes:
Previous suicide attempts:
Between 6% and 13% of adolescents have reported that they attempted suicide at least once in
their lives (Dubow, Kausch, Blum &Reed, 1989; Gallup Organization, 1991; Meehan, Lamb,
Saltzman & O'Carroll, 1992; Shaffer, Garland, Vieland, Underwood & Busner, 1991). The
vast majoiity of suicide attempters do not seek or receive medical or mental health care
(Smith & Crawtord, 1988).
Family history of suicide:
Garfinkel, Froese and Hood (1991) found that the rate of suicide in the families of adolescent
suicide attempters was seven times greater than the rate in families of medical patients.
Suicidal adolescents are more likely than other adolescents to know someone who has either
attempted or committed suicide (Sprito, et al., 1989).
When students who attempted suicide after a close school friend completed suicide (conta-gion
effect), studies indicated that there was a significant history of psychiatric illness in these
children's families.
Psychiatric disorders including depression and hopelessness:
The most prevalent psychiatric disorders among completed adolescent suicides appear to be
mood disorders, conduct disorder and substance abuse (Brent et al., 1988); Shaffer, 1988).
Psychological difficulties are also indicated by the fact that the majority of adolescents who
commit suicide experienced long-standing problems in school, with their families and
possibly with the law.
Kazdin, French, Unis, Esveldt-Dawson and Sherick (1983) found that children who had made
a suicide attempt reported more depression and hopelessness than did children who were
suicide ideators. Hopelessness with depression may be a stronger predictor of suicidal
behavior than depression alone.
Suicidal ideation:
Smith and Crawford (1981) indicated that 62.6% of a midwestern high school sample reported
some suicidal ideation of behavior. Another study reported a lifetime prevalence of suicidal
ideation of 54% among college students (Meehan et al., 1992).
Poor impulse control:
It is characterized by a general lack of responsible, rational behavior and can be included
within such disorders as intermittent explosive disorder, many of the disruptive behavior
disorders (ADHD) and affective disorders such as bipolar disorder. When impulsivity is
combined with other risk factors such as depression and use of substances, the risk of a
suicidal episode is greatly increased.
Substance abuse and /or alcoholism:
Drug and alcohol abuse is a significant factor for suicidal behavior, both as it affects cognitive,
social, affective familial and behavioral functioning, and as an immediate precipitant to
suicide due to decreased inhibitions (Shaffer, 1988). Brent et al. (1988) found that at least one-third
of adolescents who commit suicide are intoxicated at the time of death and many more may
be under the influence of drugs.
Stressful life events, humiliating experiences and interpersonal relationships:
Hendlin (1987) reported that adolescent suicide attempters experienced more family turmoil
(such as parental separations, changes in caretakers and living situations) as well as increased
social instability in the year before the suicide attempt than did nonsuicidal adolescents and a
normal sample of adolescents.
Completed suicide is often immediately precipitated by a shameful or humiliating experience
such as an arrest, a perceived failure at school or work or a rejection or interpersonal conflict
with a romantic partner or parent (Brent et al., 1988; Shaffer, 1974,1988; Shaffer et al., 1988).
The experience of sexual or physical assault appears to be a particularly significant risk factor
for girls.
Hoberman and Garfinkel (1988) found that the most common precipitant of suicide in their
sample of 229 youth suicides was an argument with a boyfriend of girlfriend or a parent
(19%), followed by school problems (14%). Brent et al. (1988) reported that an interpersonal
conflict was a precipitant in more than 70% of the suicides they studied. Additionally, when a
person has poor impulse control, they experience increased difficulties in resolving interper-sonal
conflicts due to deficits in problem solving skills (Rotheram-Borus, Trautman, Depkins
& Shrout, 1990).
Gender identity issues:
Gay youth are two to three times more likely to attempt suicide than other young people
(Larkin Street, 1984). While there is nothing inherently self-destructive in homosexual feelings
and relationships, suicide attempts by gay and lesbian youth are likely to involve conflicts
around sexual orientation because of the overwhelming pressures they face in coming out at
an early age (Bell and Weinberg, 1978). The Los Angeles Suicide Prevention Center found that
the strongest causative indicators of suicidal behavior among gay youth were awareness of
their sexual orientation, depression and suicidal feelings, all before the age of 14 (Los Angeles
Suicide Prevention Center, 1986).
Accessibility of firearms:
The rate of suicide by firearms has increased three times faster than the rates of all other
methods for 15-19 year olds since 1950 (Boyd & Moscicki, 1986). Brent et al. (1988) reported
that there was greater availability of firearms in homes of adolescents who completed suicide
than in homes of adolescents who had made suicide attempts.
Increased pressure to perform:
Elkind (1981) attributed the dramatic increase in adolescent suicide to increased pressure on
children to achieve and to be responsible at an early age.
Prominent display of suicide in the media:
Several studies have confirmed that suicide rates increase following television or newspaper
coverage of suicide, and that teenagers appear to be particularly susceptible to this effect
(Gould & Shaffer, 1986; Phillips & Carstenson, 1988). Fictional stories about suicide have
also been found to be associated with an increase in suicidal behavior (Gould & Shaffer,
1986). It is not clear how or whether the manner in which the information is presented
influences the effect.
Factors that tend to mitigate these trends include the presence of a stable home and community
environment, individual protective factors, positive school experiences and primary prevention
programming in social and educational settings.
The objective of secondary prevention is to identify adolescents at risk and ensure that they receive
appropriate, timely mental health care. Friends of teenagers who have attempted suicide are clearly
among those at risk and intervention programs can identify them and prevent a contagion effect.
Comprehensive mental health care for those at risk should be readily available, affordable and
accessible regardless of geographic location and economic status. Professionals in settings in which
identification is likely (e.g. the schools, medical care facilities, youth centers and crisis intervention
centers/hotlines), should be well informed regarding the risk factors and the protocol for making
mental health referrals. Additional training at various levels will be required to achieve this. The
mental health care system includes qualified professionals such as counselors, nurses, primary care
physicians and pediatricians, social workers, psychologists and psychiatrists.
Tertiary prevention involves controlling events after a suicidal episode. This includes obtaining care
for the adolescent and/or providing support to the family, friends and others impacted by a suicidal
episode. Tertiary prevention also includes decreasing media coverage and glamorization of suicide.
The risk and prevention factors associated with adolescent suicidal episodes are now becoming much
more clearly defined. Finding the resources to implement a continuum of care remains challenging.
Conclusions
Suicidal behavior is an outcome of psychiatric disorders in combination with exacerbating
circumstances.
The most common psychiatric disorders associated with suicide are depression, impulse
control disorders and substance abuse.
Suicidal behavior is most common among youth where there is a family history of psychiatric
disorders and suicide.
Prevention of suicide among adolescents lies in the earliest possible identification of
psychiatric disorders and initiation of appropriate treatment.
Many violent and/or homicidal acts are a result of psychiatric disorders turned outward into
aggressive acts of violence.
Stigmatization surrounding gender identity issues is strongly associated with suicidal
behavior.
The use of firearms is strongly associated with completed suicides.
There is a serious lack of available, accessible and timely services as well as inadequate
coordination among the agencies that encounter and intervene in the lives of young people at
risk.
Recommendations
Early, systematic identification and treatment are essential for children and youth at risk for
suicidal episodes.
Children and youth must have universal access to mental health care.
Appropriate training for professionals should be developed and required.
Existing services should be coordinated and consolidated with the addition of a centralized
information line and data collection and tracking system.
Serious efforts to control access to firearms among children and youth should be initiated.
Arizona's Child Fatality Review Team should be strongly encouraged to review
adolescent suicidal episodes and develop prevention and early intervention strategies.
SUPPORTING MATERIALS
The following flow chart visually represents factors that tend to increase or decrease the risk of
suicidal episodes. A suicidal episode is defined as an occurrence of suicidal ideation, threats, attempts
or completion or any combination of these factors (Pffeffer et al., 1991).
In addition, a hypothetical case study has been included to illustrate a possible scenario. Problems
included are those that are likely to be encountered within the various systems that frequently interact
with children and youth at risk. Points of contact with these systems are also highlighted with
suggested interventions.
ADOLESCENT SUICIDE RISK AND PREVENTION
RISK FACTORS PREVENTION FACTORS
SUICIDAL EPISODE TERTIARY PREVENTION
Obtain care after event
CASE STUDY
AN ADOLESCENT SUICIDE ATTEMPTER
A fourteen year old white male was brought to the emergency room by police following a suspicious
single car accident. He had borrowed his mother's car, run off the road, hit a tree and was treated for
a concussion and minor injuries. He was under the influence of alcohol at the time of the accident.
He was upset about his mother's nagging him about not going to school. He also appeared despon-dent
and depressed. He was admitted for a 72 hour evaluation and the Regional Behavioral Health
Authority (RBHA) was asked to assess his behavioral health needs.
This 14 year old male had been to the emergency room on various occasions for injuries sustained
during one prior auto accident and numerous fights. His mother indicated that drugs or alcohol were
involved on all occasions. The mother, a 30 year old single white female living in an urban area, was
mildly mentally retarded and could not remember the exact times or locations of the previous hospi-talizations.
She worked part-time cleaning houses. There was a 11 year old sister. The mother was
not married but both children had the same father. She reported that neither she nor the father had
completed high school. Both families, apparently, had some history of depression and suicidal
episodes. The father was presently incarcerated in the state prison for child molestation of his daugh-ter
and another neighborhood girl. Child Protective Services (CPS) was involved at the time of the
disclosure of molestation and the daughter had been briefly placed in foster care. She was returned to
her mother when the father was arrested and removed from the home.
The mother had communication difficulties but believed her son had become increasingly depressed
over the past six months and she suspected that he was involved with a local gang. She stated that
her
son is also mildly mentally retarded and is in special education classes at the public school. Addition-ally,
the boy had suffered from grand ma1 seizures since he was three years old. They have been
partially controlled by medication which he takes irregularly. The family receives medical care
through AHCCCS.
The boy has always done poorly in school but recently his attendance has been very irregular. The
principal discussed this with the mother on several occasions. She stated that she cannot control her
son and can't force him to go to school. He has been spending more and more time with friends and
recently his mother found a gun in his room. The police have been called for various neighborhood
incidents of fighting and, at one point, he threatened to kill his mother and his sister with a knife.
Charges were not pressed.
The young man stated that he hates school because others make fun of him because he is slow and
weird and the only place where he feels accepted is among his gang who are school dropouts. His
sister indicated to the emergency room staff that she has been worried about her brother for some
time. He once told her when he was drunk that he felt like dying.
SYSTEMS ISSUES
In the previous case study there are various points at which interventions could have occurred to
assist the youth and his family but did not or were not sufficient to ensure timely and appropriate
services.
This youth was identified at age three as having neurological problems manifested through grand ma1
seizures and poor fine motor coordination. Although he received medication for this condition, no
known referrals were provided at this time for neuropsychiatric or developmental disability (DD)
assessment. His mild mental retardation was not discovered until he was in second grade when he
was referred for behavior problems and testing.
Testing provided through the school resulted in a recommendation for placement in special education,
however, he was not placed until he was in 5th grade. By this time, his achievement had further
declined and his behavior problems had worsened. Because his medication was not effectively
monitored, he continued to experience seizures at school.
The special education teacher noticed signs of depression which she discussed with the mother. The
teacher suggested sources for assistance but the mother did not pursue them. The boy's acting out
behavior increased over the years as his achievement declined. By the time he reached the junior
high school level, his attendance was poor and school staff suspected gang involvement. Several
incidents involving the police resulted in brief detentions but no follow up behavioral health services.
The most recent incident led to emergency room treatment and the 72 hour evaluatiorl through the
local Regional Behavioral Health Authority (RBHA). The evaluation revealed severe depression with
conduct disorder. Although the boy admitted to suicidal thoughts, he was not deemed actively
suicidal at discharge. A treatment plan was developed by the RBHA which included in-home therapy
and medication monitoring. Although he was placed on antidepressants, he did not take them
regularly, refused to attend the in-home therapy sessions, ran away on several occasions and had
several additional skirmishes with police.
Since this treatment was not successful, a staffing was held by the RBHA to address future planning.
Results of the staffing included recommendations for services through Developmental Disabilities in
cooperation with the RHBA for a therapeutic group home placement. This recommendation was the
result of escalating concerns about the boy's deteriorating mental and physical condition and
increased risk for suicide.
The RBHA and the Department of Developmental Disabilities disagreed over the child's primary
diagnosis which affected placement decisions and funding responsibilities. Additionally, in the most
recent school individual education plan (IEP), the school district recommended residential treatment
since they considered the child to be uncontrollable in his current setting. DDD considered the need
for intensive residential service to be totally related to behavioral health issues rather than seizures or
retardation.
The RBHA believed that a DD group home with wrap around behavioral health services was the most
appropriate intervention clinically and most cost effective since costs would be shared.
The Behavioral Health Services Medical Director was contacted by the school district due to Hodges v.
Bishop mandates and the child was placed in residential treatment.
The RBHA appealed this decision for clinical reasons. In addition, the full burden of funding was
their responsibility until the child became eligible for Title XIX behavioral health services.
POINTS OF INTERVENTION
In an ideal system, interventions would occur at the earliest point and comprehensive, preventive
services would be provided. The following list illustrates points of possible entry and treatment or
services that could have been accessed.
CRITICAL POINT POSSIBLE INTERVENTION
The mother was a teenager when
her child was born. She could have
been identified as high risk during her
pregnancy or at the birth of her child.
Her developmental delay could have
been discovered at this time.
Services for high-risk mothers such as
Healthy Families could have been provided.
If the developmental delay was discovered,
the mother may have been eligible for
services through Developmental Disabilities.
A pediatrician discovered the boy's seizure Referrals for neurological and
disorder when he was three years old. developmental assessments would have
been appropriate. If results indicated the
need, referrals to DDD or Behavioral Health
Services could have been made.
The boy entered school at age 5 or 6.
Mental deficiencies and continuing
medical problems might have been
discovered.
In second grade problems were identified
and recommendations were made for a
special education placement. Placement
did not occur until 3 years later.
The special education teacher noticed that
the boy seemed depressed and suggested
that the mother seek counseling. The
mother did not follow through.
The boy was involved in various minor
skirmishes with the police and briefly
detained.
The boy was brought to the emergency
room on several occasions for minor
injuries sustained in fights.
Appropriate remedial strategies or referrals
could have been initiated by the school
nurse or other staff upon initial screening.
Special education services could have been
implemented immediately.
When the mother did not follow the
teacher's suggestions, the teacher could
have discussed the case with the school
psychologist. Teacher or psychologist could
have met with the mother and suggested
other available resources.
These incidents could have resulted in
juvenile court intervention and court
ordered treatment could have occurred at
this time.
Emergency room staff should have made
referrals to have the youth evaluated.
FIGURE 1
STATES WITH THE HIGHEST AND LOWEST RATES OF SUICIDE
for
PERSONS 10 - 24 YEARS OF AGE, 1987 - 1988
Hawm
Highest death rates Lowest death rates
Source: Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death
and Related Risk Behaviors among U. S. Adolescents. p. 33.
FIGURE 2
Source: Mrela, C. K. (1994). Arizona Department of Health Services
SUICIDE MORTALITY AMONG ARIZONA'S
ADOLESCENTS 15-1 9 YEARS OLD BY YEAR FROM
1982 TO 1992 AND COMPARISON WITH YEAR 2000
HEALTH OBJECTIVE
22 -
Number of suicide deaths per 100,OOD
adolescent^ 15-19 pears old:
19--
16--
10
x - x - x -
I I I I I I I I I 4
1982 1983 1984 1985 1986 1987 1988' 1989 1990 1991 1992
YEAR
Note: the straight line is the trend line calculated by a leaat-square approximation method
- known also as a simple linear regression.
REFERENCES
American Psychiatric Association. (1987). Diagnostic and statistical manual ofmental disorders:
(3rd. ed., Revised). Washington, D. C.: Author.
Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death and Related
Risk Behaviors Among U. S. Adolescents. Atlanta: Author.
Gersten, J. C. & Mrela, C. K. (1990). Closing the Decade: Arizona Health Status and Vital
Statistics, 1980 - 1989. Phoenix: Arizona Department of Health Services.
McIntosh, J. L. (1993). Methods of Suicide. Denver: American Association of Suicidology.
Mrela, C. K. (1991). Suicide Mortality: Arizona, 1980 - 1989. Phoenix: Arizona Department of
Health Services.
Mrela, C. K. (1992). Suicide Mortality: Arizana, 1990. Phoenix: Arizona Department of Health
Services.
Mrela, C. K. (1993). Suicide Mortality: Arizona, 1991. Phoenix: Arizona Department of Health
Services.
Mrela, C.K. (1994). Patterns ofMovtality by Ethnic Group. Phoenix: Arizona Department of Health
Services.
PSYCHIATRIC DIAGNOSES AND RISK FACTORS
SUBCOMMITTEE
• REPORT and RECOMMENDATIONS
a
a
ADOLESCENT SUICIDE RISK AND PREVENTION
Dramatic demographic and social changes occurring during the latter half of the twentieth century in
the United States have contributed to social and personal disorganization. Demographic changes
include urbanization, population mobility and increasing numbers of poor, uneducated, unemployed
and disadvantaged members of society. Social factors include the decline in religious/moral values,
prevalence of divorce and the startling increase in the number of single-parent families. Earlier
initiation of sexual activity, increased unintentional pregnancies, sexually transmitted diseases, child
abuse, domestic violence, increased criminal activity all tend to exacerbate the situation.
Stigmatization surrounding gender identity conflicts is an additional factor.
These societal stressors appear to be associated with feelings of anger, alienation and hopelessness
among vulnerable individuals, including adolescents. When associated with psychiatric illness,
especially depression, individuals may experience loss of self-esteem, decreased coping skills and a
loss of hope. Trigger factors such as the use of alcohol or drugs, the availability of a lethal method
(particularly firearms) and the occurrence of stressful life events may increase the likelihood of a
suicidal episode.
Risk Factors for Adolescent Suicidal Episodes:
Previous suicide attempts:
Between 6% and 13% of adolescents have reported that they attempted suicide at least once in
their lives (Dubow, Kausch, Blum & Reed, 1989; Gallup Organization, 1991; Meehan, Lamb,
Saltzman & O'Carroll, 1992; Shaffer, Garland, Vieland, Underwood & Busner, 1991). The
vast majority af suicide attempters do not seek or receive medical or mental health care
(Smit'~& Crawford, 1988).
Family history of suicide:
Garfinkel, Froese and Hood (1991) found that the rate of suicide in the families of adolescent
suicide attempters was seven times greater than the rate in families of medical patients.
Suicidal adolescents are more likely than other adolescents to know someone who has either
attempted or committed suicide (Sprito, et al., 1989).
When students who attempted suicide after a close school friend completed suicide (conta-gion
effect), studies indicated that there was a significant history of psychiatric illness in these
children's families.
Psychiatric disorders including depression and hopelessness:
The most prevalent psychiatric disorders among completed adolescent suicides appear to be
mood disorders, conduct disorder and substance abuse (Brent et al., 1988); Shaffer, 1988).
Psychological difficulties are also indicated by the fact that the majority of adolescents who
commit suicide experienced long-standing problems in school, with their families and
possibly with the law.
Kazdin, French, Unis, Esveldt-Dawson and Sherick (1983) found that children who had made
a suicide attempt reported more depression and hopelessness than did children who were
suicide ideators. Hopelessness with depression may be a stronger predictor of suicidal
behavior than depression alone.
Suicidal ideation:
Smith and Crawford (1981) indicated that 62.6% of a midwestern high school sample reported
some suicidal ideation of behavior. Another study reported a lifetime prevalence of suicidal
ideation of 54% among college students (Meehan et al., 1992).
Poor impulse control:
It is characterized by a general lack of responsible, rational behavior and can be included
within such disorders as intermittent explosive disorder, many of the disruptive behavior
disorders (ADHD) and affective disorders such as bipolar disorder. When impulsivity is
combined with other risk factors such as depression and use of substances, the risk of a
suicidal episode is greatly increased.
Substance abuse and /or alcoholism:
Drug and alcohol abuse is a significant factor for suicidal behavior, both as it affects cognitive,
social, affective familial and behavioral functioning, and as an immediate precipitant to
suicide due to decreased inhibitions (Shaffer, 1988). Brent et al. (1988) found that at least one-third
of adolescents who commit suicide are intoxicated at the time of death and many more may
be under the influence of drugs.
Stressful life events, humiliating experiences and interpersonal relationships:
Hendlin (1987) reported that adolescent suicide attempters experienced more family turmoil
(such as parental separations, changes in caretakers and living situations) as well as increased
social instability in the year before the suicide attempt than did nonsuicidal adolescents and a
normal sample of adolescents.
Completed suicide is often immediately precipitated by a shameful or humiliating experience
such as an arrest, a perceived failure at school or work or a rejection or interpersonal conflict
with a romantic partner or parent (Brent et al., 1988; Shaffer, 1974,1988; Shaffer et al., 1988).
The experience of sexual or physical assault appears to be a particularly significant risk factor
for girls.
Hoberman and Garfinkel (1988) found that the most common precipitant of suicide in their
sample of 229 youth suicides was an argument with a boyfriend of girlfriend or a parent
(19%), followed by school problems (14%). Brent et al. (1988) reported that an interpersonal
conflict was a precipitant in more than 70% of the suicides they studied. Additionally, when a
person has poor impulse control, they experience increased difficulties in resolving interper-sonal
conflicts due to deficits in problem solving skills (Rotheram-Borus, Trautman, Depkins
& Shrout, 1990).
Gender identity issues:
Gay youth are two to three times more likely to attempt suicide than other young people
(Larkin Street, 1984). While there is nothing inherently self-destructive in homosexual feelings
and relationships, suicide attempts by gay and lesbian youth are likely to involve conflicts
around sexual orientation because of the overwhelming pressures they face in coming out at
an early age (Bell and Weinberg, 1978). The Los Angeles Suicide Prevention Center found that
the strongest causative indicators of suicidal behavior among gay youth were awareness of
their sexual orientation, depression and suicidal feelings, all before the age of 14 (Los Angeles
Suicide Prevention Center, 1986).
Accessibility of firearms:
The rate of suicide by firearms has increased three times faster than the rates of all other
methods for 15-19 year olds since 1950 (Boyd & Moscicki, 1986). Brent et al. (1988) reported
that there was greater availability of firearms in homes of adolescents who completed suicide
than in homes of adolescents who had made suicide attempts.
Increased pressure to perform:
Elkind (1981) attributed the dramatic increase in adolescent suicide to increased pressure on
children to achieve and to be responsible at an early age.
Prominent display of suicide in the media:
Several studies have confirmed that suicide rates increase following television or newspaper
coverage of suicide, and that teenagers appear to be particularly susceptible to this effect
(Gould & Shaffer, 1986; Phillips & Carstenson, 1988). Fictional stories about suicide have
also been found to be associated with an increase in suicidal behavior (Gould & Shaffer,
1986). It is not clear how or whether the manner in which the information is presented
influences the effect.
Factors that tend to mitigate these trends include the presence of a stable home and community
environment, individual protective factors, positive school experiences and primary prevention
programming in social and educational settings.
The objective of secondary prevention is to identify adolescents at risk and ensure that they receive
appropriate, timely mental health care. Friends of teenagers who have attempted suicide are clearly
among those at risk and intervention programs can identify them and prevent a contagion effect.
Comprehensive mental health care for those at risk should be readily available, affordable and
accessible regardless of geographic location and economic status. Professionals in settings in which
identification is likely (e.g. the schools, medical care facilities, youth centers and crisis intervention
centers/hotlines), should be well informed regarding the risk factors and the protocol for making
mental health referrals. Additional training at various levels will be required to achieve this. The
mental health care system includes qualified professionals such as counselors, nurses, primary care
physicians and pediatricians, social workers, psychologists and psychiatrists.
Tertiary prevention involves controlling events after a suicidal episode. This includes obtaining care
for the adolescent and/or providing support to the family, friends and others impacted by a suicidal
episode. Tertiary prevention also includes decreasing media coverage and glamorization of suicide.
The risk and prevention factors associated with adolescent suicidal episodes are now becoming much
more clearly defined. Finding the resources to implement a continuum of care remains challenging.
Conclusions
Suicidal behavior is an outcome of psychiatric disorders in combination with exacerbating
circumstances.
The most common psychiatric disorders associated with suicide are depression, impulse
control disorders and substance abuse.
Suicidal behavior is most common among youth where there is a family history of psychiatric
disorders and suicide.
Prevention of suicide among adolescents lies in the earliest possible identification of
psychiatric disorders and initiation of appropriate treatment.
Many violent and/or homicidal acts are a result of psychiatric disorders turned outward into
aggressive acts of violence.
Stigmatization surrounding gender identity issues is strongly associated with suicidal
behavior.
The use of firearms is strongly associated with completed suicides.
There is a serious lack of available, accessible and timely services as well as inadequate
coordination among the agencies that encounter and intervene in the lives of young people at
risk.
Recommendations
Early, systematic identification and treatment are essential for children and youth at risk for
suicidal episodes.
Children and youth must have universal access to mental health care.
Appropriate training for professionals should be developed and required.
Existing services should be coordinated and consolidated with the addition of a centralized
information line and data collection and tracking system.
Serious efforts to control access to firearms among children and youth should be initiated.
Arizona's Child Fatality Review Team should be strongly encouraged to review
adolescent suicidal episodes and develop prevention and early intervention strategies.
SUPPORTING MATERIALS
The following flow chart visually represents factors that tend to increase or decrease the risk of
suicidal episodes. A suicidal episode is defined as an occurrence of suicidal ideation, threats, attempts
or completion or any combination of these factors (Pffeffer et al., 1991).
In addition, a hypothetical case study has been included to illustrate a possible scenario. Problems
included are those that are likely to be encountered within the various systems that frequently interact
with children and youth at risk. Points of contact with these systems are also highlighted with
suggested interventions.
ADOLESCENT SUICIDE RISK AND PREVENTION
RISK FACTORS PREVENTION FACTORS
TERTIARY PREVENTION
Obtain care after event
CASE STUDY
AN ADOLESCENT SUICIDE ATTEMPTER
A fourteen year old white male was brought to the emergency room by police following a suspicious
single car accident. He had borrowed his mother's car, run off the road, hit a tree and was treated for
a concussion and minor injuries. He was under the influence of alcohol at the time of the accident.
He was upset about his mother's nagging him about not going to school. He also appeared despon-dent
and depressed. He was admitted for a 72 hour evaluation and the Regional Behavioral Health
Authority (RBHA) was asked to assess his behavioral health needs.
This 14 year old male had been to the emergency room on various occasions for injuries sustained
during one prior auto accident and numerous fights. His mother indicated that drugs or alcohol were
involved on all occasions. The mother, a 30 year old single white female living in an urban area, was
mildly mentally retarded and could not remember the exact times or locations of the previous hospi-talizations.
She worked part-time cleaning houses. There was a 11 year old sister. The mother was
not married but both children had the same father. She reported that neither she nor the father had
completed high school. Both families, apparently, had some history of depression and suicidal
episodes. The father was presently incarcerated in the state prison for child molestation of his daugh-ter
and another neighborhood girl. Child Protective Services (CPS) was involved at the time of the
disclosure of molestation and the daughter had been briefly placed in foster care. She was returned to
her mother when the father was arrested and removed from the home.
The mother had communication difficulties but believed her son had become increasingly depressed
over the past six months and she suspected that he was involved with a local gang. She stated that
her
son is also mildly mentally retarded and is in special education classes at the public school. Addition-ally,
the boy had suffered from grand ma1 seizures since he was three years old. They have been
partially controlled by medication which he takes irregularly. The family receives medical care
through AHCCCS.
The boy has always done poorly in school but recently his attendance has been very irregular. The
principal discussed this with the mother on several occasions. She stated that she cannot control her
son and can't force him to go to school. He has been spending more and more time with friends and
recently his mother found a gun in his room. The police have been called for various neighborhood
incidents of fighting and, at one point, he threatened to kill his mother and his sister with a knife.
Charges were not pressed.
The young man stated that he hates school because others make fun of him because he is slow and
weird and the only place where he feels accepted is among his gang who are school dropouts. His
sister indicated to the emergency room staff that she has been worried about her brother for some
time. He once told her when he was drunk that he felt like dying.
SYSTEMS ISSUES
In the previous case study there are various points at which interventions could have occurred to
assist the youth and his family but did not or were not sufficient to ensure timely and appropriate
services.
This youth was identified at age three as having neurological problems manifested through grand ma1
seizures and poor fine motor coordination. Although he received medication for this condition, no
known referrals were provided at this time for neuropsychiatric or developmental disability (DD)
assessment. His mild mental retardation was not discovered until he was in second grade when he
was referred for behavior problems and testing.
Testing provided through the school resulted in a recommendation for placement in special education,
however, he was not placed until he was in 5th grade. By this time, his achievement had further
declined and his behavior problems had worsened. Because his medication was not effectively
monitored, he continued to experience seizures at school.
The special education teacher noticed signs of depression which she discussed with the mother. The
teacher suggested sources for assistance but the mother did not pursue them. The boy's acting out
behavior increased over the years as his achievement declined. By the time he reached the junior
high school level, his attendance was poor and school staff suspected gang involvement. Several
incidents involving the police resulted in brief detentions but no follow up behavioral health services.
The most recent incident led to emergency room treatment and the 72 hour evaluation through the
local Regional Behavioral Health Authority (RBHA). The evaluation revealed severe depression with
conduct disorder. Although the boy admitted to suicidal thoughts, he was not deemed actively
suicidal at discharge. A treatment plan was developed by the RBHA which included in-home therapy
and medication monitoring. Although he was placed on antidepressants, he did not take them
regularly, refused to attend the in-home therapy sessions, ran away on several occasions and had
several additional skirmishes with police.
Since this treatment was not successful, a staffing was held by the RBHA to address future planning.
Results of the staffing included recommendations for services through Developmental Disabilities in
cooperation with the RHBA for a therapeutic group home placement. This recommendation was the
result of escalating concerns about the boy's deteriorating mental and physical condition and
increased risk for suicide.
The RBHA and the Department of Developmental Disabilities disagreed over the child's primary
diagnosis which affected placement decisions and funding responsibilities. Additionally, in the most
recent school individual education plan (IEP), the school district recommended residential treatment
since they considered the child to be uncontrollable in his current setting. DDD considered the need
for intensive residential service to be totally related to behavioral health issues rather than seizures or
retardation.
The RBHA believed that a DD group home with wrap around behavioral health services was the most
appropriate intervention clinically and most cost effective since costs would be shared.
The Behavioral Health Services Medical Director was contacted by the school district due to Hodges v.
Bishop mandates and the child was placed in residential treatment.
The RBHA appealed this decision for clinical reasons. In addition, the full burden of funding was
their responsibility until the child became eligible for Title XIX behavioral health services.
POINTS OF INTERVENTION
In an ideal system, interventions would occur at the earliest point and comprehensive, preventive
services would be provided. The following list illustrates points of possible entry and treatment or
services that could have been accessed.
CRITICAL POINT POSSIBLE INTERVENTION
The mother was a teenager when
her child was born. She could have
been identified as high risk during her
pregnancy or at the birth of her child.
Her developmental delay could have
been discovered at this time.
Services for high-risk mothers such as
Healthy Families could have been provided.
If the developmental delay was discovered,
the mother may have been eligible for
services through Developmental Disabilities.
A pediatrician discovered the boy's seizure Referrals for neurological and
disorder when he was three years old. developmental assessments would have
been appropriate. If results indicated the
need, referrals to DDD or Behavioral Health
Services could have been made.
The boy entered school at age 5 or 6.
Mental deficiencies and continuing
medical problems might have been
discovered.
In second grade problems were identified
and recommendations were made for a
special education placement. Placement
did not occur until 3 years later.
The special education teacher noticed that
the boy seemed depressed and suggested
that the mother seek counseling. The
mother did not follow through.
The boy was involved in various minor
skirmishes with the police and briefly
detained.
The boy was brought to the emergency
room on several occasions for minor
injuries sustained in fights.
Appropriate remedial strategies or referrals
could have been initiated by the school
nurse or other staff upon initial screening.
Special education services could have been
implemented immediately.
When the mother did not follow the
teacher's suggestions, the teacher could
have discussed the case with the school
psychologist. Teacher or psychologist could
have met with the mother and suggested
other available resources.
These incidents could have resulted in
juvenile court intervention and court
ordered treatment could have occurred at
this time.
Emergency room staff should have made
referrals to have the youth evaluated.
Policies and Procedures
Every school district is required by law (A.R.S. 15-345) to have written chemical abuse (alcohol and
other drug use) policy and procedures. It is highly recommended that such policy and procedures be
broad and comprehensive to include identifying and assisting students or staff who are not only at
risk for chemical abuse but might also be at risk for suicidal behavior.
Technical Assistance, Training for School Districts, and the Development and Dissemination of
Prevention Curriculum
Arizona is fortunate to have available a wide variety of resources for technical assistance and training
regarding prevention. One of those resources is the Arizona Prevention Resource Center (APRC)
which is Arizona's central source for prevention information and materials. In addition to providing
materials for special target and high risk populations, the APRC can provide a network of trainers,
educators, and consultants, entitled "PeopleLinks," to provide effective training and technical assis-tance
to schools in developing, implementing, and evaluating their comprehensive school/community
prevention efforts. The Arizona Prevention Resource Center is a cooperative effort of four state
agencies: the Governor's Office of Drug Policy, the Arizona Department of Education, the Arizona
Department of Health Services, and Arizona State University, College of Extended Education. It is
recommended that school districts take advantage of these excellent services.
CONCLUSIONS AND RECOMMENDATIONS
Comprehensive programs that include primary, secondary and tertiary activities should be in
place in all schools in Arizona.
An integrated prevention curriculum should emphasize protective factors, resilience, positive
health and well-being.
Preservice training should be provided in all teacher education programs in the state.
All classroom teachers should be provided with adequate inservice training in the develop-ment
and use of integrated prevention curriculum.
A multidisciplinary child study team (CST) or crisis response team (CRT) should be
established in each school to implement assessment, intervention and referral procedures.
This team should collaborate with local mental health agencies.
Each school should establish guidelines for dealing with death or traumatic events in the
school or community. An inservice training for all faculty and staff should include training
in the policies and procedures for managing a crisis or traumatic event.
The chemical abuse policy and procedures that are required by law (ARS 15-345) should be
broad and comprehensive to include identifying and assisting students or staff who are not
only at risk for chemical abuse but might be at risk for suicidal behavior.
Support groups should be provided for students that have been identified as at-risk for self-defeating
behaviors.
REFERENCES
Public Health Service, Center for Disease Control. (1991a). Chronic disease and health
promotion: Youth risk behavior surveillance system. Washington, DC: U.S. Department of
Health and Human Services.
Public Health Service. (1991b). Healthy people 2000: National health promotion and disease
preventiun objectives-full report with commentary. Washington, DC: U.S. Department of
Health and Human Services.
Arizona Department of Health Services, Office of Planning and Health Status Monitoring. (1991).
Suicide mortality Arizona, 1980-1989. Phoenix, AZ: Author.
Arizona Department of Education, Special Programs Division, Comprehensive Health Unit. (1991).
Model policy and procedures: Alcohol and other drug prevention. Phoenix, AZ: Author.
Arizona Department of Education. (August, 1992). Chemical abuse prevention program
evaluation (CAPPE): Executive Summary. Phoenix, AZ: Author.
Shaffer, D., Garland, A. & Whittle, B. (1988). An evaluation of youth suicide prevention programs.
Unpublished report.
Shaffer, D., Garland, A., Vieland, V., Underwood, M. & Busner, C. (1991). The impact of
curriculum-based suicide prevention programs for teenagers. Journal of the American
Academy of Child & Adolescent Psychiaty, 30,588-596.
Shaffer, D., Vieland, V., Garland, A., Rojas, M. Underwood, M., & Busner, C. (1990). Adolescent
suicide attempters: Response to suicide prevention programs. Journal of the American
Medical Association, 264, 3151 -3155.
COMMUNITY BASED PROGRAMS SUBCOMMITTEE
COMMUNITY BASED PROGRAMS SUBCOMMITTEE REPORT
Assisting suicidal youth or teenagers in need of behavioral health services is not an easy task.
Traditional community-based counseling services are generally not utilized by the teenage
population. This approach tends to be geared toward the adult population and does not effectively
address the adolescent in crisis. In general, adolescents rarely seek help from a mental health
professional. According to Offer et al. (1991), the majority of distressed adolescents would be
willing to go to a school-based clinic, prefer to talk to friends and parents regarding emotional
problems, and find the help from both friends and parents beneficial. While nondisturbed
adolescents prefer to turn to their parents for help, disturbed adolescents usually turn to friends.
For those adolescents who did seek help from a behavioral health professional, Earls (1989) indicated
that only one quarter of adolescents in treatment reported their suicidal thoughts or attempts to the
clinic they attended. Of those adolescents who did report, it was done at either a school-based and/or
neighborhood-based clinic. Thus, utilizing new modalities to reach teenagers in a nonthreatening
manner becomes a key component in effectively addressing the behavioral health needs of this
population. If teenagers will not come to a traditional behavioral health setting, moving these services
to a nontraditional setting is vital. Locating such services in youth centers then becomes a viable
option.
Location, however, is not the only barrier to accessing services. Adolescents seeking services face
many other obstacles within the existing behavioral health system. Reducing the barriers or guiding
teens through them is therefore necessary to ensure that youth receive help.
Also, training for those who are likely to come into contact with suicidal youth is vital. Rotheram-
Borus (1989) suggested that those individuals who work with youth (teachers, recreation leaders, staff
at runaway shelters, ministers, etc.) should be able to identify and intervene with suicidal youth.
Consequently, gatekeeper training on basic behavioral health issues as well as suicide assessment is
necessary.
Another key component in reaching this population can be provided in two ways: utilizing a hotline
and peer counselor/helpers. Shaffer et al. (1988) suggested that hotlines and crisis services can be
beneficial with the adolescent population if the service is an identifiable service by teens in the
community, a 24-hour service, and advertised in the presence of the target group. Staffing a hotline
with "teen volunteers" can be helpful in reaching adolescents. Utilizing teens in suicide prevention
and intervention can be an important tool. Brent et. a1 (1988) reported that of those adolescents who
completed suicide, 83 percent had made a statement of their intent within the week of the suicide.
One-half had reported their intent to a friend or sibling only. Enlisting the help of friends and
siblings can improve the mechanism by which at risk youth are identified and referred for treatment.
Training natural and peer helpers can be an effective technique in identifying these young people.
Caplan (1989) suggested using natural helpers as a supportive network. Training for these helpers in
school and community settings is important.
Finally, after adolescents have sought help, it is important that they feel the services are relevant to
teen issues. Nelson et. al. (1988) stated that adolescents desire more relevancy in services provided.
Programs need to be geared toward the life experiences that youth find to be most meaningful.
This study recommended the availability of counseling and educational programs as well as a
supportive environment in the community for youth in crisis. Youth stressed the importance of
informal counseling and support. All groups surveyed reported the need to befriend and talk to
young people, to provide support in a loving way, and family support as key elements in an
intervention program. "Educational programs and intervention designs to prevent youth suicide
should address attitudes about communication and identify barriers to open communication among
adolescents themselves and their adult caregivers." (Nelson, 1988, p. 41)
RECOMMENDATIONS
One 24-hour statewide behavioral health hotline should be established for referral,
information and advocacy and should include a peer counseling component.
o Comprehensive, coordinated "gatekeeper" training should be available, especially regarding
adolescent depression, alcohol/drug assessment, suicide assessment and referrals.
o The availability of counseling, educational and meaningful recreational programs conducted
in a supportive community environment for youth in crisis should be increased. A team
approach coordinated at one site (one-stop shopping) is desirable.
Parental education regarding the significant danger of suicidal ideation, gestures and attempts
should be available. Parents should be provided with basic information on warning signs,
risk factors as well as information on how to access behavioral health services. This report
may serve to partially satisfy this need.
REFERENCES
Brent, D., Perper, J., Goldstein, C. Kolka, D., Allan, M., Aliman, C. & Zelenak, J. (1988). Risk
factors for adolescent suicide. Arch General Psychiatry 45, 581-588.
Caplan G. (1989). Recent developments in crisis intervention and the promotion of support service.
Journal of Primary Prevention, 10(1), 3-25.
Earls, F. (1989). Studying adolescent suicidal ideation and behavior in primary care settings.
Suicide and Life-Threatening Behavior, 19(1), 99-107.
Nelson, F. L., Farberow, N., & Litrnan, R. (1988). Youth suicide in California: A comparative study
of perceived causes and interventions. Community Mental Health Journal, 24 (I), 31-42.
Offer, D., Howard, K. I., Schonert, K. A. & Ostrov, E. (1991). To who do adolescents turn for help?
Differences between disturbed and nondisturbed adolescents. Journal of American Academy
of Child and Adolescent Psychiatry, 30 (4), 623-630.
Rotheram-Borus, M. J. (1991). Evaluation of suicide risk among youths in community settings.
Suicide and Life-Threatening Behavior, 19 (I), 108-119
Shaffer, D., Garland, A., Gould, M., Fisher, P., & Trautman, P. (1988). Preventing teenage suicide: a
critical review. Journal of American Academy of Child and Adolescent Psychiatry, 27( 6), 675-687.
Simmons, J. T. (1989). Prevention/intervention programs for suicidal adolescents. Report of the
Secretary's Task Force on Youth Suicide. Washington D.C.: U. S. Department of Health and
Human Services.
APPENDIX A
INTERVENTION PROCEDURES
INTERVENTION PROCEDURES
Suicide Crisis Response
Flagstaff Unified School District
A Crisis Response Team (CRT) will be established in each school in order to implement referral,
assessment, intervention or postvention procedures in situations related to suicidal risk or suicide
General Responsibilities of Crisis Response Team members:
1. Help faculty and staff understand symptoms and signals of potential suicidal behavior
and understand referral procedures.
2. Compile and keep current a confidential list of "at-risk" students; review and revise
list at periodic intervals.
Referral Response:
Only those members of the CRT who are trained as mental health professionals
(Counselors, school psychologists) and who have received suicide assessment/intervention
training may assess risk factors in order that appropriate procedures may be followed.
Referral Procedures:
1. A referral is made by a teacher, parent, staff member, friend, etc.
2. A member of the CRT qualified to make an assessment of risk factors will contact the
student.
3. The meeting with the student should result in a determination of whether the case
appears to be low risk, medium risk, or high risk. When there is a question on the part
of the CRT member or the supervisor of counseling and psychological services will
occur.
The following procedures should be followed depending upon the judgment made as to level of risk:
LOW RISK
Low Risk is characterized by communication of a double message; for example, a student
may say he/she has no suicidal thoughts, but his/her behavior contradicts this. At least some
low level objective data that suicide is a consideration ( such as journal entries). The student
may be mildly upset or mildly depressed; however, the depression is generally not chronic.
The student is undergoing or has recently gone through some crisis. There is a basic support
available to the student.
With any low-risk threat, contact the parent(s)/legal guardian(s). The CRT member should
call the parent(s)/legal guardiads) and inform them of the concerns and what is going on
with their child.
There is probably no need for the parent(s)/legal guardian(s) to come to school to pick up the
student(though parents(s)/legal guardian($ may wish to do so).
The CRT member will supply a list of outside referral sources. In addition to outside
referrals, the student may participate in an assistance program on campus.
The student's name is added to the list of at risk students maintained by the CRT.
MEDIUM RISK
Medium Risk is characterized by having a suicide plan which is not highly lethal; the means
to complete suicide plan are not immediately available; chronic depression is a factor, but the
student hasn't acted on it; implementing a suicide plan is not as imminent as with "high
suicide risk"; the student has an escalating preoccupation with suicide; the student expresses
ambivalence regarding suicide; the student may reach out for help.
The principal of the school is notified of the potential risk.
The parent(s)/legal guardian(s) is notified of the risk involved. The student is required to stay
with CRT member or other designated school personnel until the parent amved to have a
conference and to transport the student home and/or to treatment.
The CRT member will make a referral for outside professional assistance, supplying referral
sources. In addition to outside assistance, a student may participate in a student assistance
program on campus.
Follow-up is required. An appointment time and date will be set for the CRT member or a
designated person to see the student again. Additional follow-up may involve the school's
contacting the student's therapist, psychologist or psychiatrist directly. Help may be enlisted
from the student's teacher to monitor the situation.
Feedback about the disposition of the case is provided to the referral source.
The student's name is added to the list of at-risk students maintained by the CRT.
HIGH RISK
High Risk is characterized by the student having a suicide plan which is immediate and
highly lethal; is in imminent danger of self-harm; previous suicide attempts; appearance of
suffering from acute depression, a history of suicide/suicide attempts among family or
friends and feelings of helplessness and hopelessness or stated intent to die.
The principal of the school is notified of the potential risk for a student suicide.
The parent(s)/legal guardian(s) is notified of the risk involved. The student is required to stay
with the CRT member or other school personnel until the parent(s)/legal guardian(s) arrives
to have a conference and to transport the student to a treatment source.
The CRT member will supply a list of possible outside referral sources and assist the parent in
obtaining immediate intervention. If the parent(s)/legal guardian($ refuses to take the
student for outside professional help despite the school's effort to facilitate this, a report
should immediately be made to Child Protective Services. The student may also participate in
a student assistance program on campus.
When there is reason to believe the student is in immediate danger, the proper/or appropriate law
enforcement agency should be notified of the situation so that the student may receive appropriate
outside assessment and treatment. This may be done without the permission of parent(s)/legal
guardian(s), if they cannot be reached, under the following regulations (Title 34-99.36):
A. An educational agency or institution may disclose personally identifiable information
from the education records of a student to appropriate parties in connection with an
emergency if knowledge of the information is necessary to protect the health or safety
of the student or other individual.
B. The factors to be taken into account in determining whether personally identifiable
information from the education records of a student may be disclosed under this
section shall include the following:
1. The seriousness of the threat to the health or safety of the student or other
individuals,
2. The need for the information to meet the emergency,
3. Whether the parties to whom the information is disclosed are in a position to
deal with the emergency and
4. The extent to which time is of the essence in dealing with the emergency.
School personnel should never transport a student to a hospital or other care facility. The
police of parent(s)/legal guardian(s) are responsible for transporting.
Follow-up is required. The CRT member or designated person will set an appointment date
and time to see the student again when the student returns to school. Monitoring will occur to
determine if the student is receiving follow-up outside help. If this is not occurring, the
parent will be contacted again to be urged to obtain these services. Faculty help is monitoring
the situation will be solicited. Follow-up may involve the CRT member or designated person
contacting the student's therapist, psychologist or psychiatrist directly.
o Feedback about the disposition of the case is provided to the referral source, strong support
and praise for referring are recommended. Students who refer and/or intervene should be
assured that they have done the right thing in order for the person to receive help.
The student's name is added to the list of at-risk students maintained by the CRT.
Response to Off-Campus Attempts:
A CRT member will:
1. Call the parent(s)/legal guardian($ to verify the situation and determine probable
absence time.
2. Contact the student's teachers and request assignments, if appropriate.
3. Monitor the e student's friend, and/or follow-up on other students who may be
perceived to be risks.
4. Work with the parent(s)/legal guardian(s) and/or other professionals involved with
the student to share relevant information.
5. Upon the student's return, determine whether outside counseling is being provided
and by whom. Periodic contact and support should be provided by a CRT member or
designated person.
Response to Suicide:
1. An administrator calls to verify and obtain appropriate details. The same
administrator notified the district office.
2. The supervisor of counseling and psychological services will initiate a phone tree to
notify district members and request assistance as appropriate
3. Contact all administrators, counselors, the student's teachers, school psychologist and
nurse to inform them of the incident and request their presence at a faculty meeting.
4. Depending on time factors, a telephone tree is strongly suggested to notify faculty of
the suicide and request their presence at a faculty meeting.
5. Hold a faculty meeting to discuss procedures for the day and relay the facts about the
suicide. The following guidelines are suggested for teachers:
a. If there is likely to be a strong widespread response by many students, a
designated periods early in the day as possible should be encouraged for
classroom discussion rather than repeating discussions all day long.
b. Students should be allowed to talk about the suicide and their feelings.
Students who may appear to be having significant problems should be
escorted to a CRT member or counselor. Another student who appears to be
emotionally in control may do the escorting.
c. Class sessions through the remainder of the day should follow a relatively
normal routine, but with added flexibility. Attention spans are likely to be
shorter, students may still initiate questions or discussion related to the
suicide, and some students may show or demonstrate emotional upset to the
degree that a referral to the guidance department is in order.
d. In addition to allowing students to process feelings, teachers, particularly in
the period designated for discussion, may wish to share the following ideas
with their students:
While it is extremely regrettable that a young person has chose suicide,
students should think about the positive in their own lives and take
care of themselves.
o Referrals to the counseling department should be an option for
students feeling particularly troubled.
Help students understand that no single factor causes a suicide.
There is always more than one problem, usually of an ongoing
nature.
No one person can be responsible for the suicide death of another and
that even highly trained professionals cannot always predict it.
If a friend threatens suicide, teachers should be sure that the friend is
referred to a professional helper. Students should know it's okay to
break a confidence if it means it might save a life.
If a staff meeting is not possible, disseminate information about the suicide to all teachers and
inform them of what procedures to follow.
Call the district supervisor of counseling and psychological services, inform of theincident,
and, if needed, request the support of a district team to come to the building to work with
school personnel and students.
Contact the victim's parent(s)/legal guardian(s) to offer assistance and determine additional
action.
Continue with a normal school schedule, excusing students to attend the services.
Designate one school staff member to be the media spokesperson. Ask all other staff to refer
any media contacts to the designated spokesperson. Statements to the media should be
limited so as not to "dramatize" the occurrence, which could increase chances of "imitations".
Statements expressing regret and that the school has a plan to offer intervention and support are
probably sufficient. No personal statements about the victim or hidher family should be given.
Students who are possibly at risk for imitating the event should be contacted to assess how
they are doing.
Provide an opportunity through individual contacts or small groups for the victim's circle of
friends to discuss their feelings.
Adult support groups should be made available by the counseling department asappropriate
as soon as possible after the occurrence. Meetings such as these help to dispel feelings of
helplessness and frustration.
Teachers should be made aware of symptoms/signals and should be encouraged to refer
students who may be in need of help.
In Case of an Attempted or Completed On-Campus Suicide:
1. Notify an administrator immediately.
2. Notify district office and all CRT members immediately.
3. If an attempt, the nurse and an administrator will determine if the situation requires
immediate medical attention. If so:
a. The administrator will immediately notify the police and call for an
ambulance.
b. The parent(s)/guardian(s) should be notified immediately.
c. Have all CRT members available to deal with other students involved. Try to
keep students and faculty members away from the immediate crisis area.
Isolate any witnesses and/or friends with help from team members.
d. Notify the district office and supervisor of counseling and psychological
services for immediate assistance.
e. Refer all requests from the media to the district office. Make no comment.
Do not release information until after the crisis is over.
Arizona Department of Education, Comprehensive Health Unit (1991). Model Policy and
Procedures fur School District Alcohol and Other Drug Prevention Programs, pp. 23-28.

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ADOLESCENT SUICIDE TASK FORCE
REPORT and RECOMMENDATIONS
THE GOVERNOR'S OFFICE FOR CHILDREN
Fife Symington, Governor
Lynne N. Gallagher, Director
Eric Benjamin, M.D., Chair
Janet M. Wise, Project Coordinator
May, 1994
With special thanks to Robert Schackner of the Child Fatality Review Program,
Arizona Department of Health Services
THE ADOLESCENT SUICIDE TASK FORCE
Cheryl Collier Becker
Mental Health Association of Maricopa County
Phoenix
Eric Benjamin, M.D., Chair
Phoenix Children's Hospital
Phoenix
Ilene Dode, Ph.D.
Empact Suicide Prevention Center
Tempe
Roger Griggs
White Mountain Apache Tribe
Whiteriver
Steven Kalas
Empact Suicide Prevention Center
Tempe
Jettie McWilliams, Ed.D.
Northern Arizona University
Phoenix
Arlene Metha, Ph.D.
Arizona State University
Tempe
Michelle Moorhead
Teen LifeLine
Phoenix
iii
Barbara Olson
Arizona Department of Health Services
Phoenix
Joel Sadowsky
Dances with Opportunities
Tucson
Robert Schackner
Arizona Department of Health Services
Phoenix
Sandra Sperry
Peoria Unified School District
Peoria
Vicky Stromee
Help on Call
Tucson
Margaret Walker
White Mountain Apache Tribe
Whiteriver
Tom Welter
Welter, Incorporated
Mesa
Janet M. Wise
Governor's Office for Children
TABLE OF CONTENTS
Executive Summary .......................................................................... ix
Introduction and Background .............................................................. 1
Psychiatric Diagnoses and Risk Factors Subcommittee Report ........................... 11
School-Based Prevention Programs Subcommittee Report ............................... 25
Community-Based Programs Subcommittee Report ...................................... 31
Appendix A: Crisis Intervention Procedures ........................................ 35
EXECUTIVE SUMMARY
by Eric Benjamin, M.D.
The first question I asked the members of the Adolescent Suicide Task Force upon becoming
chairman was, "Must one have a psychiatric disorder in order to experience a suicidal episode?" A
suicidal episode is defined as an occurrence of suicidal ideation, threats, attempts, completion or any
combination of these factors. After much research and debate, the members concluded that, indeed,
almost all suicidal individuals have a psychiatric disorder as defined in the Diagnostic and Statistical
Manual of Mental Disorders, third edition, revised (DSM-111-R).
We found that those at risk for suicide had depressive disorders, or other mood disorders, impulse
control disorders such as Attention Deficit Hyperactivity Disorder (ADHD), and frequently a family
history of suicide or previous suicidal episodes. In addition, substance abuse or alcoholism further
enhanced the risk. The access to a lethal method, particularly firearms, increased the likelihood of a
completed suicide.
Not all young people with these psychiatric disorders commit suicide. Psychiatrically disordered
children and adolescents are at greater risk if they are from disrupted families with lower levels of
education, low economic status, or if they are raised in environments where they are chronically
exposed to abuse, violence or criminal activity.
Therefore our recommendations follow from these well-researched findings:
1. Those children whose biological parents or relatives have a family history of previous
suicidal episodes must be screened and monitored as part of their early health care.
This is a genetically at-risk population of children who are vulnerable to suicidal
behavior. These children must have universal access to mental health care from the
time behavioral problems are first noted (i.e., in school, by parents, by a pediatrician,
etc.). Timely treatment of this population will serve to prevent the morbidity and
mortality that is associated with suicidal episodes.
2. Children and youth with depressive disorders and other mood disorders, impulse
control disorders (ADHD) and drug or alcohol problems must also have universal
access to mental health services. Again, a family history for these disorders increases
the risk that these children will have similar problems through inheritance.
3. The availability of firearms to children and youth predisposes this vulnerable
population to a greater rate of suicide completion. Thus, there should be stringent
control of the availability of firearms to children and adolescents. When there is a
family history of suicidal episodes or the psychiatric disorders described above,
specific safeguards should be in place if firearms are to be present in the home.
We strongly urge legislators and the general public to understand that suicide and homicide are two
indicators of the status of mental health of our children and adolescents. Both of these behaviors are
the outcomes of psychiatrically disturbed youth having access to lethal means where there are few
social supports or treatments in place. Indeed, homicidal or aggressive behavior is the outward
display of poor impulse control and mood disorders, often in combination with alcohol and drug
problems, learning disorders or other psychiatric disorders. Identification of this at-risk population
as described above, with early treatment, will prevent the morbidity and mortality for both the
individual and society. This will be reflected not only in lives saved, but in monetary savings as well.
As we approach the twenty-first century, Prevention should become the treatment approach for these
psychiatrically disordered children as early as possible in life. Thus, a three-year-old exhibiting
impulse control problems in a chaotic home environment where homicidal or suicidal behavior has
occurred in the parents or relatives requires immediate access to long-term mental health care. The
price tag of identifying and treating this child, when compared to the cost of paying for his
habilitation as an adult is minimal, particularly when one considers that he may contribute to society
in a productive manner if treated.
The Adolescent Suicide Task Force has explored various programs, both at school and in the
community, including school-based prevention programs and crisis hotlines to identify children and
adolescents at risk. We have also detailed paradigms to be implemented to help in this task.
Ultimately, the funding of the programs designed to triage and initiate treatment of these youths, at
school and in the community, and the funding of the mental health care delivery system to assess and
maintain treatment will provide the means to prevent suicide, homicide, and other aggressive
behavioral disorders in children, adolescents and adults. The return on this investment will be a safer,
healthier world at less cost to society.
INTRODUCTION
The Adolescent Suicide Task Force, organized in November, 1991, is an outgrowth of the State Select
Commission on Adolescent Suicide that was originally convened in September, 1988. This
Commission produced a Prevention Program Guide and submitted a Report of its activities to the
Governor in September, 1989. This Report recommended increased funding for behavioral health
services and coordination among state agencies to reduce fragmentation and maximize resources.
In spite of these efforts, the problem of suicide among teenagers and young adults in Arizona has
remained serious. When Marti Lavis assumed the Directorship of the Governor's Office for Children
in April, 1991, several members of the State Select Commission asked her to organize a group to
study the problem and develop new strategies for decreasing suicides among Arizona's most
important resource, its youth.
Dr. Eric Benjamin, Medical Director of Child and Adolescent Psychiatry at Phoenix Children's
Hospital, was named Chair in March, 1992, and has provided able leadership since that time. Under
his direction, the Task Force conducted a review of the substantial literature that exists on the subject
of teen suicide and divided into three subcommittees to study specific aspects of the issue. These
subcommittees included:
Psychiatric Diagnoses and Risk Factors
School-based Prevention Programs
Hotlines, Crisis Intervention and other Community Programs
The following report is the result of two years' work on the part of the Task Force and its
subcommittees. Although the Task Force has experienced many challenges during this period, it
has continued to work toward a greater understanding of the problem and identification of realistic
strategies to improve outcomes.
But recommendations, no matter how well researched or articulated, are empty words without the
will to translate them into reality. The ultimate success of the Task Force will depend upon its mes-sage
being heard and addressed across the state in homes, schools, mental health centers and among
those who set priorities and make decisions at the state level.
Teen suicide cannot be seen in isolation. Often the culmination of failed hopes, nonexistent
opportunities and unmet mental health needs, it is exacerbated by the conditions facing young people
today. These include poverty, broken families, substance abuse and rapidly escalating violence. It is
critical that we as a state begin to address these primary issues if the condition of our children and
youth is ever to improve.
BACKGROUND
DEFINITIONS AND RISK FACTORS
Suicidal Ideation - Persistent thoughts or ideas about killing oneself.
Suicidal Threat - Involves thoughts about killing oneself as well as overt expression of these thoughts.
Suicide Attempt - A self-inflicted act with the intent to cause injury.
Suicidal Episode - An occurrence of suicidal ideation, threats, attempts, completion or any
combination of these factors.
Psychiatric Disorders - Conditions described in the Diagnostic and Statistical Manual of Mental
Disorders (Third Edition - Revised).
Adolescence - The period of physical and psychological development from the onset of puberty to
maturity. Exact age markers cannot be assigned to this transition because individuals enter and leave
it at different ages. Usually, however, adolescence takes place between the ages of 10 and 24. Within
this transitional period, there are several developmental tasks to be completed:
Transition from dependence on family to independence.
o Development of identity and sense of social responsibility.
Development of mature personal relationships including sexual relationships.
Identification of career goals and acquisition of skills necessary for economic
independence.
Risk Factors Associated with Adolescent Suicidal Episodes - See the second section of this report
for a more complete description of these factors.
Previous suicide attempts.
Suicidal ideation.
Family history of suicidal episodes.
Psychiatric disorders.
Depression and hopelessness.
Poor impulse control.
Substance abuse and/or alcoholism
Stressful life events and humiliating experiences.
Disturbed interpersonal relationships.
Gender identity issues.
Accessibility of firearms.
Prominent display of suicide in the media.
ADOLESCENT SUICIDE IN ARIZONA
Throughout the decade of the 1980s and the early 1990s, the suicide rate in Arizona has been among
the highest in the nation. This is true for persons of all ages as well as for adolescents. From 1985
through 1989, Arizona's rate of suicide for persons of all ages ranked among the five worst while its
average rate for persons between 15 - 24 ranked eighth (Mrela, 1991). Mrela stated that, "The 1991
Arizona suicide rate was 50.9 percent higher than the national rate, and 58.1 percent higher than the
year 2000 national health objective of 10.5 suicides/100,000 population." (1991, p. 4) Table 1
provides comparisons of suicide rates and numbers over a ten year period for three age groups.
TABLE 1
NUMBER OF SUICIDES AND SUICIDE RATES 1982 - 1992
Other states with high rates of suicide are, with few exceptions, Rocky Mountain States (Centers for
Disease Control and Prevention, 1993). Figure 1 shows the states with the highest and lowest suicide
rates for individuals between 10 and 24 years of ages for the years 1987 and 1988. Although there
has been considerable speculation about the cluster of high rates in the West, a definitive answer does
not appear to be available. Possible explanations include isolation, transient populations and higher
rates among Native Americans. Although each of these has merit, none seems to hold true for all the
states involved.
In Arizona, the theory of transiency is not consistent with other trends. Teenagers in urban environ-ments,
where transiency is greatest, were not killing themselves with the same frequency as rural
youths. From 1980 to 1989, the increase in teen suicide rates was 3.4 times greater for rural teens
(Gersten & Mrela, 1990). In 1991, the counties with the highest suicide rates for persons 15 - 24 were
rural counties with the highest rates of all seen in Apache, Cochise, Pinal and Yavapai (Mrela, 1993).
The suicide rate for individuals 15 through 19 years of age has increased steadily between 1981 and
1991 while the rate for persons 20 - 24 has declined slightly (Mrela, 1993). Figure 2 illustrates the
trend toward increasing rates among teenagers.
Although the number of suicide attempts is believed to be much greater among females, the number
of completions is considerably higher among males. In 1991, There were 40 deaths by suicide
among males 15-19 years of age and 9 among females in the same age group. In the young adult
age group, 20 - 24, a similar difference was evident. In 1991, there were 52 males who killed
themselves and 10 females (Mrela, 1993).
The highest suicide rates for Arizona youth are among white males and Native American males. The
rate for Native Americans teens of both sexes was especially high in 1990 (40.2 deaths per 100,000
population). This rate was more than twice the rate for white teenagers (18.7) and almost nine times
the rate for hispanics (4.6) (Mrela, 1992).
According to the American Association of Suicidology (1993), the most common method of suicide
is use of firearms. Nationally, 61.1 % of the suicides for persons of all ages in 1990 were the result of
firearms. The second most common method in 1990 was hanging, strangulation or suffocation
which accounted for 14.4% of all suicides. This was followed by ingestion of solid or liquid poisons
which accounted for 10.2% of all deaths by suicide.
A somewhat different mix of methods is observed in attempted suicide. Most common is the
overdose of medication, often in combination with other substances. Attempts also involve jumping
from high places, use of cutting instruments such as knives and razors as well as hanging, gassing and
traffic accidents.
In Arizona, firearms accounted for 67.6 % of all suicides from 1989 to 1991. Most of the increase in
suicides among young people can be accounted for by use of firearms.
It seems likely that actual attempts and completions are significantly more numerous than reported
figures indicate. Many suicidal episodes and actual attempts are never reported. Also, it is frequently
difficult to determine whether certain fatalities are planned or accidental, especially those involving
motor vehicles. For this reason, the Task Force has chosen to emphasize suicidal episodes rather than
completions.
FIGURE 3
STATES WITH THE HIGHEST AND LOWEST RATES OF SUICIDE
for
PERSONS 10 - 24 YEARS OF AGE, 1987 - 1988
Hawm~
Highest death rates Lowest death rates
Source: Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death
and Related Risk Behaviors among U. S. Adolescents. p. 33.
FIGURE 2
Source: Mrela, C. K. (1994). Arizona Department of Health Services
8
SUICIDE MORTALITY AMONG ARIZONA'S
ADOLESCENTS 15-1 9 YEARS OLD BY YEAR FROM
1982 TO 1992 AND COMPARISON WITH YEAR 2000
HEALTH OBJECTIVE
22 -
Number of suicide deaths per lD0,DDD
adolescent8 15- 1 9 years old:
19--
16--
10
x--x--x--*--x-
I I I I I I I I I
1982 1983 1984 1985 1986 1987 1988' 1989 1990 1991 1992
YEAR
Note: the fltraight line is the trend line calculated by a least-square approximation method
known also as a simple linear regression.
REFERENCES
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders:
(3rd. ed., Revised). Washington, D. C.: Author.
Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death and Related
Risk Behaviurs Among U. S. Adolescents. Atlanta: Author.
Gersten, J. C. & Mrela, C. K. (1990). Closing the Decade: Arizona Health Status and Vital
Statistics, 1980 - 1989. Phoenix: Arizona Department of Health Services.
McIntosh, J. L. (1993). Methods of Suicide. Denver: American Association of Suicidology.
Mrela, C. K. (1991). Suicide Mortality: Arizona, 1980 - 1989. Phoenix: Arizona Department of
Health Services.
Mrela, C. K. (1992). Suicide h4ortality: Arizona, 1990. Phoenix: Arizona Department of Health
Services.
Mrela, C. K. (1993). Suicide Mortality: Arizana, 1991. Phoenix: Arizona Department of Health
Services.
Mrela, C.K. (1994). Pattms ofMortality by Ethnic Group. Phoenix: Arizona Department of Health
Services.
PSYCHIATRIC DIAGNOSES AND RISK FACTORS
SUBCOMMITTEE
REPORT and RECOMMENDATIONS
ADOLESCENT SUICIDE RISK AND PREVENTION
Dramatic demographic and social changes occurring during the latter half of the twentieth century in
the United States have contributed to social and personal disorganization. Demographic changes
include urbanization, population mobility and increasing numbers of poor, uneducated, unemployed
and disadvantaged members of society. Social factors include the decline in religious/moral values,
prevalence of divorce and the startling increase in the number of single-parent families. Earlier
initiation of sexual activity, increased unintentional pregnancies, sexually transmitted diseases, child
abuse, domestic violence, increased criminal activity all tend to exacerbate the situation.
Stigmatization surrounding gender identity conflicts is an additional factor.
These societal stressors appear to be associated with feelings of anger, alienation and hopelessness
among vulnerable individuals, including adolescents. When associated with psychiatric illness,
especially depression, individuals may experience loss of self-esteem, decreased coping skills and a
loss of hope. Trigger factors such as the use of alcohol or drugs, the availability of a lethal method
(particularly firearms) and the occurrence of stressful life events may increase the likelihood of a
suicidal episode.
Risk Factors for Adolescent Suicidal Episodes:
Previous suicide attempts:
Between 6% and 13% of adolescents have reported that they attempted suicide at least once in
their lives (Dubow, Kausch, Blum &Reed, 1989; Gallup Organization, 1991; Meehan, Lamb,
Saltzman & O'Carroll, 1992; Shaffer, Garland, Vieland, Underwood & Busner, 1991). The
vast majoiity of suicide attempters do not seek or receive medical or mental health care
(Smith & Crawtord, 1988).
Family history of suicide:
Garfinkel, Froese and Hood (1991) found that the rate of suicide in the families of adolescent
suicide attempters was seven times greater than the rate in families of medical patients.
Suicidal adolescents are more likely than other adolescents to know someone who has either
attempted or committed suicide (Sprito, et al., 1989).
When students who attempted suicide after a close school friend completed suicide (conta-gion
effect), studies indicated that there was a significant history of psychiatric illness in these
children's families.
Psychiatric disorders including depression and hopelessness:
The most prevalent psychiatric disorders among completed adolescent suicides appear to be
mood disorders, conduct disorder and substance abuse (Brent et al., 1988); Shaffer, 1988).
Psychological difficulties are also indicated by the fact that the majority of adolescents who
commit suicide experienced long-standing problems in school, with their families and
possibly with the law.
Kazdin, French, Unis, Esveldt-Dawson and Sherick (1983) found that children who had made
a suicide attempt reported more depression and hopelessness than did children who were
suicide ideators. Hopelessness with depression may be a stronger predictor of suicidal
behavior than depression alone.
Suicidal ideation:
Smith and Crawford (1981) indicated that 62.6% of a midwestern high school sample reported
some suicidal ideation of behavior. Another study reported a lifetime prevalence of suicidal
ideation of 54% among college students (Meehan et al., 1992).
Poor impulse control:
It is characterized by a general lack of responsible, rational behavior and can be included
within such disorders as intermittent explosive disorder, many of the disruptive behavior
disorders (ADHD) and affective disorders such as bipolar disorder. When impulsivity is
combined with other risk factors such as depression and use of substances, the risk of a
suicidal episode is greatly increased.
Substance abuse and /or alcoholism:
Drug and alcohol abuse is a significant factor for suicidal behavior, both as it affects cognitive,
social, affective familial and behavioral functioning, and as an immediate precipitant to
suicide due to decreased inhibitions (Shaffer, 1988). Brent et al. (1988) found that at least one-third
of adolescents who commit suicide are intoxicated at the time of death and many more may
be under the influence of drugs.
Stressful life events, humiliating experiences and interpersonal relationships:
Hendlin (1987) reported that adolescent suicide attempters experienced more family turmoil
(such as parental separations, changes in caretakers and living situations) as well as increased
social instability in the year before the suicide attempt than did nonsuicidal adolescents and a
normal sample of adolescents.
Completed suicide is often immediately precipitated by a shameful or humiliating experience
such as an arrest, a perceived failure at school or work or a rejection or interpersonal conflict
with a romantic partner or parent (Brent et al., 1988; Shaffer, 1974,1988; Shaffer et al., 1988).
The experience of sexual or physical assault appears to be a particularly significant risk factor
for girls.
Hoberman and Garfinkel (1988) found that the most common precipitant of suicide in their
sample of 229 youth suicides was an argument with a boyfriend of girlfriend or a parent
(19%), followed by school problems (14%). Brent et al. (1988) reported that an interpersonal
conflict was a precipitant in more than 70% of the suicides they studied. Additionally, when a
person has poor impulse control, they experience increased difficulties in resolving interper-sonal
conflicts due to deficits in problem solving skills (Rotheram-Borus, Trautman, Depkins
& Shrout, 1990).
Gender identity issues:
Gay youth are two to three times more likely to attempt suicide than other young people
(Larkin Street, 1984). While there is nothing inherently self-destructive in homosexual feelings
and relationships, suicide attempts by gay and lesbian youth are likely to involve conflicts
around sexual orientation because of the overwhelming pressures they face in coming out at
an early age (Bell and Weinberg, 1978). The Los Angeles Suicide Prevention Center found that
the strongest causative indicators of suicidal behavior among gay youth were awareness of
their sexual orientation, depression and suicidal feelings, all before the age of 14 (Los Angeles
Suicide Prevention Center, 1986).
Accessibility of firearms:
The rate of suicide by firearms has increased three times faster than the rates of all other
methods for 15-19 year olds since 1950 (Boyd & Moscicki, 1986). Brent et al. (1988) reported
that there was greater availability of firearms in homes of adolescents who completed suicide
than in homes of adolescents who had made suicide attempts.
Increased pressure to perform:
Elkind (1981) attributed the dramatic increase in adolescent suicide to increased pressure on
children to achieve and to be responsible at an early age.
Prominent display of suicide in the media:
Several studies have confirmed that suicide rates increase following television or newspaper
coverage of suicide, and that teenagers appear to be particularly susceptible to this effect
(Gould & Shaffer, 1986; Phillips & Carstenson, 1988). Fictional stories about suicide have
also been found to be associated with an increase in suicidal behavior (Gould & Shaffer,
1986). It is not clear how or whether the manner in which the information is presented
influences the effect.
Factors that tend to mitigate these trends include the presence of a stable home and community
environment, individual protective factors, positive school experiences and primary prevention
programming in social and educational settings.
The objective of secondary prevention is to identify adolescents at risk and ensure that they receive
appropriate, timely mental health care. Friends of teenagers who have attempted suicide are clearly
among those at risk and intervention programs can identify them and prevent a contagion effect.
Comprehensive mental health care for those at risk should be readily available, affordable and
accessible regardless of geographic location and economic status. Professionals in settings in which
identification is likely (e.g. the schools, medical care facilities, youth centers and crisis intervention
centers/hotlines), should be well informed regarding the risk factors and the protocol for making
mental health referrals. Additional training at various levels will be required to achieve this. The
mental health care system includes qualified professionals such as counselors, nurses, primary care
physicians and pediatricians, social workers, psychologists and psychiatrists.
Tertiary prevention involves controlling events after a suicidal episode. This includes obtaining care
for the adolescent and/or providing support to the family, friends and others impacted by a suicidal
episode. Tertiary prevention also includes decreasing media coverage and glamorization of suicide.
The risk and prevention factors associated with adolescent suicidal episodes are now becoming much
more clearly defined. Finding the resources to implement a continuum of care remains challenging.
Conclusions
Suicidal behavior is an outcome of psychiatric disorders in combination with exacerbating
circumstances.
The most common psychiatric disorders associated with suicide are depression, impulse
control disorders and substance abuse.
Suicidal behavior is most common among youth where there is a family history of psychiatric
disorders and suicide.
Prevention of suicide among adolescents lies in the earliest possible identification of
psychiatric disorders and initiation of appropriate treatment.
Many violent and/or homicidal acts are a result of psychiatric disorders turned outward into
aggressive acts of violence.
Stigmatization surrounding gender identity issues is strongly associated with suicidal
behavior.
The use of firearms is strongly associated with completed suicides.
There is a serious lack of available, accessible and timely services as well as inadequate
coordination among the agencies that encounter and intervene in the lives of young people at
risk.
Recommendations
Early, systematic identification and treatment are essential for children and youth at risk for
suicidal episodes.
Children and youth must have universal access to mental health care.
Appropriate training for professionals should be developed and required.
Existing services should be coordinated and consolidated with the addition of a centralized
information line and data collection and tracking system.
Serious efforts to control access to firearms among children and youth should be initiated.
Arizona's Child Fatality Review Team should be strongly encouraged to review
adolescent suicidal episodes and develop prevention and early intervention strategies.
SUPPORTING MATERIALS
The following flow chart visually represents factors that tend to increase or decrease the risk of
suicidal episodes. A suicidal episode is defined as an occurrence of suicidal ideation, threats, attempts
or completion or any combination of these factors (Pffeffer et al., 1991).
In addition, a hypothetical case study has been included to illustrate a possible scenario. Problems
included are those that are likely to be encountered within the various systems that frequently interact
with children and youth at risk. Points of contact with these systems are also highlighted with
suggested interventions.
ADOLESCENT SUICIDE RISK AND PREVENTION
RISK FACTORS PREVENTION FACTORS
SUICIDAL EPISODE TERTIARY PREVENTION
Obtain care after event
CASE STUDY
AN ADOLESCENT SUICIDE ATTEMPTER
A fourteen year old white male was brought to the emergency room by police following a suspicious
single car accident. He had borrowed his mother's car, run off the road, hit a tree and was treated for
a concussion and minor injuries. He was under the influence of alcohol at the time of the accident.
He was upset about his mother's nagging him about not going to school. He also appeared despon-dent
and depressed. He was admitted for a 72 hour evaluation and the Regional Behavioral Health
Authority (RBHA) was asked to assess his behavioral health needs.
This 14 year old male had been to the emergency room on various occasions for injuries sustained
during one prior auto accident and numerous fights. His mother indicated that drugs or alcohol were
involved on all occasions. The mother, a 30 year old single white female living in an urban area, was
mildly mentally retarded and could not remember the exact times or locations of the previous hospi-talizations.
She worked part-time cleaning houses. There was a 11 year old sister. The mother was
not married but both children had the same father. She reported that neither she nor the father had
completed high school. Both families, apparently, had some history of depression and suicidal
episodes. The father was presently incarcerated in the state prison for child molestation of his daugh-ter
and another neighborhood girl. Child Protective Services (CPS) was involved at the time of the
disclosure of molestation and the daughter had been briefly placed in foster care. She was returned to
her mother when the father was arrested and removed from the home.
The mother had communication difficulties but believed her son had become increasingly depressed
over the past six months and she suspected that he was involved with a local gang. She stated that
her
son is also mildly mentally retarded and is in special education classes at the public school. Addition-ally,
the boy had suffered from grand ma1 seizures since he was three years old. They have been
partially controlled by medication which he takes irregularly. The family receives medical care
through AHCCCS.
The boy has always done poorly in school but recently his attendance has been very irregular. The
principal discussed this with the mother on several occasions. She stated that she cannot control her
son and can't force him to go to school. He has been spending more and more time with friends and
recently his mother found a gun in his room. The police have been called for various neighborhood
incidents of fighting and, at one point, he threatened to kill his mother and his sister with a knife.
Charges were not pressed.
The young man stated that he hates school because others make fun of him because he is slow and
weird and the only place where he feels accepted is among his gang who are school dropouts. His
sister indicated to the emergency room staff that she has been worried about her brother for some
time. He once told her when he was drunk that he felt like dying.
SYSTEMS ISSUES
In the previous case study there are various points at which interventions could have occurred to
assist the youth and his family but did not or were not sufficient to ensure timely and appropriate
services.
This youth was identified at age three as having neurological problems manifested through grand ma1
seizures and poor fine motor coordination. Although he received medication for this condition, no
known referrals were provided at this time for neuropsychiatric or developmental disability (DD)
assessment. His mild mental retardation was not discovered until he was in second grade when he
was referred for behavior problems and testing.
Testing provided through the school resulted in a recommendation for placement in special education,
however, he was not placed until he was in 5th grade. By this time, his achievement had further
declined and his behavior problems had worsened. Because his medication was not effectively
monitored, he continued to experience seizures at school.
The special education teacher noticed signs of depression which she discussed with the mother. The
teacher suggested sources for assistance but the mother did not pursue them. The boy's acting out
behavior increased over the years as his achievement declined. By the time he reached the junior
high school level, his attendance was poor and school staff suspected gang involvement. Several
incidents involving the police resulted in brief detentions but no follow up behavioral health services.
The most recent incident led to emergency room treatment and the 72 hour evaluatiorl through the
local Regional Behavioral Health Authority (RBHA). The evaluation revealed severe depression with
conduct disorder. Although the boy admitted to suicidal thoughts, he was not deemed actively
suicidal at discharge. A treatment plan was developed by the RBHA which included in-home therapy
and medication monitoring. Although he was placed on antidepressants, he did not take them
regularly, refused to attend the in-home therapy sessions, ran away on several occasions and had
several additional skirmishes with police.
Since this treatment was not successful, a staffing was held by the RBHA to address future planning.
Results of the staffing included recommendations for services through Developmental Disabilities in
cooperation with the RHBA for a therapeutic group home placement. This recommendation was the
result of escalating concerns about the boy's deteriorating mental and physical condition and
increased risk for suicide.
The RBHA and the Department of Developmental Disabilities disagreed over the child's primary
diagnosis which affected placement decisions and funding responsibilities. Additionally, in the most
recent school individual education plan (IEP), the school district recommended residential treatment
since they considered the child to be uncontrollable in his current setting. DDD considered the need
for intensive residential service to be totally related to behavioral health issues rather than seizures or
retardation.
The RBHA believed that a DD group home with wrap around behavioral health services was the most
appropriate intervention clinically and most cost effective since costs would be shared.
The Behavioral Health Services Medical Director was contacted by the school district due to Hodges v.
Bishop mandates and the child was placed in residential treatment.
The RBHA appealed this decision for clinical reasons. In addition, the full burden of funding was
their responsibility until the child became eligible for Title XIX behavioral health services.
POINTS OF INTERVENTION
In an ideal system, interventions would occur at the earliest point and comprehensive, preventive
services would be provided. The following list illustrates points of possible entry and treatment or
services that could have been accessed.
CRITICAL POINT POSSIBLE INTERVENTION
The mother was a teenager when
her child was born. She could have
been identified as high risk during her
pregnancy or at the birth of her child.
Her developmental delay could have
been discovered at this time.
Services for high-risk mothers such as
Healthy Families could have been provided.
If the developmental delay was discovered,
the mother may have been eligible for
services through Developmental Disabilities.
A pediatrician discovered the boy's seizure Referrals for neurological and
disorder when he was three years old. developmental assessments would have
been appropriate. If results indicated the
need, referrals to DDD or Behavioral Health
Services could have been made.
The boy entered school at age 5 or 6.
Mental deficiencies and continuing
medical problems might have been
discovered.
In second grade problems were identified
and recommendations were made for a
special education placement. Placement
did not occur until 3 years later.
The special education teacher noticed that
the boy seemed depressed and suggested
that the mother seek counseling. The
mother did not follow through.
The boy was involved in various minor
skirmishes with the police and briefly
detained.
The boy was brought to the emergency
room on several occasions for minor
injuries sustained in fights.
Appropriate remedial strategies or referrals
could have been initiated by the school
nurse or other staff upon initial screening.
Special education services could have been
implemented immediately.
When the mother did not follow the
teacher's suggestions, the teacher could
have discussed the case with the school
psychologist. Teacher or psychologist could
have met with the mother and suggested
other available resources.
These incidents could have resulted in
juvenile court intervention and court
ordered treatment could have occurred at
this time.
Emergency room staff should have made
referrals to have the youth evaluated.
FIGURE 1
STATES WITH THE HIGHEST AND LOWEST RATES OF SUICIDE
for
PERSONS 10 - 24 YEARS OF AGE, 1987 - 1988
Hawm
Highest death rates Lowest death rates
Source: Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death
and Related Risk Behaviors among U. S. Adolescents. p. 33.
FIGURE 2
Source: Mrela, C. K. (1994). Arizona Department of Health Services
SUICIDE MORTALITY AMONG ARIZONA'S
ADOLESCENTS 15-1 9 YEARS OLD BY YEAR FROM
1982 TO 1992 AND COMPARISON WITH YEAR 2000
HEALTH OBJECTIVE
22 -
Number of suicide deaths per 100,OOD
adolescent^ 15-19 pears old:
19--
16--
10
x - x - x -
I I I I I I I I I 4
1982 1983 1984 1985 1986 1987 1988' 1989 1990 1991 1992
YEAR
Note: the straight line is the trend line calculated by a leaat-square approximation method
- known also as a simple linear regression.
REFERENCES
American Psychiatric Association. (1987). Diagnostic and statistical manual ofmental disorders:
(3rd. ed., Revised). Washington, D. C.: Author.
Centers for Disease Control and Prevention. (1993). Mortality Trends, Causes of Death and Related
Risk Behaviors Among U. S. Adolescents. Atlanta: Author.
Gersten, J. C. & Mrela, C. K. (1990). Closing the Decade: Arizona Health Status and Vital
Statistics, 1980 - 1989. Phoenix: Arizona Department of Health Services.
McIntosh, J. L. (1993). Methods of Suicide. Denver: American Association of Suicidology.
Mrela, C. K. (1991). Suicide Mortality: Arizona, 1980 - 1989. Phoenix: Arizona Department of
Health Services.
Mrela, C. K. (1992). Suicide Mortality: Arizana, 1990. Phoenix: Arizona Department of Health
Services.
Mrela, C. K. (1993). Suicide Mortality: Arizona, 1991. Phoenix: Arizona Department of Health
Services.
Mrela, C.K. (1994). Patterns ofMovtality by Ethnic Group. Phoenix: Arizona Department of Health
Services.
PSYCHIATRIC DIAGNOSES AND RISK FACTORS
SUBCOMMITTEE
• REPORT and RECOMMENDATIONS
a
a
ADOLESCENT SUICIDE RISK AND PREVENTION
Dramatic demographic and social changes occurring during the latter half of the twentieth century in
the United States have contributed to social and personal disorganization. Demographic changes
include urbanization, population mobility and increasing numbers of poor, uneducated, unemployed
and disadvantaged members of society. Social factors include the decline in religious/moral values,
prevalence of divorce and the startling increase in the number of single-parent families. Earlier
initiation of sexual activity, increased unintentional pregnancies, sexually transmitted diseases, child
abuse, domestic violence, increased criminal activity all tend to exacerbate the situation.
Stigmatization surrounding gender identity conflicts is an additional factor.
These societal stressors appear to be associated with feelings of anger, alienation and hopelessness
among vulnerable individuals, including adolescents. When associated with psychiatric illness,
especially depression, individuals may experience loss of self-esteem, decreased coping skills and a
loss of hope. Trigger factors such as the use of alcohol or drugs, the availability of a lethal method
(particularly firearms) and the occurrence of stressful life events may increase the likelihood of a
suicidal episode.
Risk Factors for Adolescent Suicidal Episodes:
Previous suicide attempts:
Between 6% and 13% of adolescents have reported that they attempted suicide at least once in
their lives (Dubow, Kausch, Blum & Reed, 1989; Gallup Organization, 1991; Meehan, Lamb,
Saltzman & O'Carroll, 1992; Shaffer, Garland, Vieland, Underwood & Busner, 1991). The
vast majority af suicide attempters do not seek or receive medical or mental health care
(Smit'~& Crawford, 1988).
Family history of suicide:
Garfinkel, Froese and Hood (1991) found that the rate of suicide in the families of adolescent
suicide attempters was seven times greater than the rate in families of medical patients.
Suicidal adolescents are more likely than other adolescents to know someone who has either
attempted or committed suicide (Sprito, et al., 1989).
When students who attempted suicide after a close school friend completed suicide (conta-gion
effect), studies indicated that there was a significant history of psychiatric illness in these
children's families.
Psychiatric disorders including depression and hopelessness:
The most prevalent psychiatric disorders among completed adolescent suicides appear to be
mood disorders, conduct disorder and substance abuse (Brent et al., 1988); Shaffer, 1988).
Psychological difficulties are also indicated by the fact that the majority of adolescents who
commit suicide experienced long-standing problems in school, with their families and
possibly with the law.
Kazdin, French, Unis, Esveldt-Dawson and Sherick (1983) found that children who had made
a suicide attempt reported more depression and hopelessness than did children who were
suicide ideators. Hopelessness with depression may be a stronger predictor of suicidal
behavior than depression alone.
Suicidal ideation:
Smith and Crawford (1981) indicated that 62.6% of a midwestern high school sample reported
some suicidal ideation of behavior. Another study reported a lifetime prevalence of suicidal
ideation of 54% among college students (Meehan et al., 1992).
Poor impulse control:
It is characterized by a general lack of responsible, rational behavior and can be included
within such disorders as intermittent explosive disorder, many of the disruptive behavior
disorders (ADHD) and affective disorders such as bipolar disorder. When impulsivity is
combined with other risk factors such as depression and use of substances, the risk of a
suicidal episode is greatly increased.
Substance abuse and /or alcoholism:
Drug and alcohol abuse is a significant factor for suicidal behavior, both as it affects cognitive,
social, affective familial and behavioral functioning, and as an immediate precipitant to
suicide due to decreased inhibitions (Shaffer, 1988). Brent et al. (1988) found that at least one-third
of adolescents who commit suicide are intoxicated at the time of death and many more may
be under the influence of drugs.
Stressful life events, humiliating experiences and interpersonal relationships:
Hendlin (1987) reported that adolescent suicide attempters experienced more family turmoil
(such as parental separations, changes in caretakers and living situations) as well as increased
social instability in the year before the suicide attempt than did nonsuicidal adolescents and a
normal sample of adolescents.
Completed suicide is often immediately precipitated by a shameful or humiliating experience
such as an arrest, a perceived failure at school or work or a rejection or interpersonal conflict
with a romantic partner or parent (Brent et al., 1988; Shaffer, 1974,1988; Shaffer et al., 1988).
The experience of sexual or physical assault appears to be a particularly significant risk factor
for girls.
Hoberman and Garfinkel (1988) found that the most common precipitant of suicide in their
sample of 229 youth suicides was an argument with a boyfriend of girlfriend or a parent
(19%), followed by school problems (14%). Brent et al. (1988) reported that an interpersonal
conflict was a precipitant in more than 70% of the suicides they studied. Additionally, when a
person has poor impulse control, they experience increased difficulties in resolving interper-sonal
conflicts due to deficits in problem solving skills (Rotheram-Borus, Trautman, Depkins
& Shrout, 1990).
Gender identity issues:
Gay youth are two to three times more likely to attempt suicide than other young people
(Larkin Street, 1984). While there is nothing inherently self-destructive in homosexual feelings
and relationships, suicide attempts by gay and lesbian youth are likely to involve conflicts
around sexual orientation because of the overwhelming pressures they face in coming out at
an early age (Bell and Weinberg, 1978). The Los Angeles Suicide Prevention Center found that
the strongest causative indicators of suicidal behavior among gay youth were awareness of
their sexual orientation, depression and suicidal feelings, all before the age of 14 (Los Angeles
Suicide Prevention Center, 1986).
Accessibility of firearms:
The rate of suicide by firearms has increased three times faster than the rates of all other
methods for 15-19 year olds since 1950 (Boyd & Moscicki, 1986). Brent et al. (1988) reported
that there was greater availability of firearms in homes of adolescents who completed suicide
than in homes of adolescents who had made suicide attempts.
Increased pressure to perform:
Elkind (1981) attributed the dramatic increase in adolescent suicide to increased pressure on
children to achieve and to be responsible at an early age.
Prominent display of suicide in the media:
Several studies have confirmed that suicide rates increase following television or newspaper
coverage of suicide, and that teenagers appear to be particularly susceptible to this effect
(Gould & Shaffer, 1986; Phillips & Carstenson, 1988). Fictional stories about suicide have
also been found to be associated with an increase in suicidal behavior (Gould & Shaffer,
1986). It is not clear how or whether the manner in which the information is presented
influences the effect.
Factors that tend to mitigate these trends include the presence of a stable home and community
environment, individual protective factors, positive school experiences and primary prevention
programming in social and educational settings.
The objective of secondary prevention is to identify adolescents at risk and ensure that they receive
appropriate, timely mental health care. Friends of teenagers who have attempted suicide are clearly
among those at risk and intervention programs can identify them and prevent a contagion effect.
Comprehensive mental health care for those at risk should be readily available, affordable and
accessible regardless of geographic location and economic status. Professionals in settings in which
identification is likely (e.g. the schools, medical care facilities, youth centers and crisis intervention
centers/hotlines), should be well informed regarding the risk factors and the protocol for making
mental health referrals. Additional training at various levels will be required to achieve this. The
mental health care system includes qualified professionals such as counselors, nurses, primary care
physicians and pediatricians, social workers, psychologists and psychiatrists.
Tertiary prevention involves controlling events after a suicidal episode. This includes obtaining care
for the adolescent and/or providing support to the family, friends and others impacted by a suicidal
episode. Tertiary prevention also includes decreasing media coverage and glamorization of suicide.
The risk and prevention factors associated with adolescent suicidal episodes are now becoming much
more clearly defined. Finding the resources to implement a continuum of care remains challenging.
Conclusions
Suicidal behavior is an outcome of psychiatric disorders in combination with exacerbating
circumstances.
The most common psychiatric disorders associated with suicide are depression, impulse
control disorders and substance abuse.
Suicidal behavior is most common among youth where there is a family history of psychiatric
disorders and suicide.
Prevention of suicide among adolescents lies in the earliest possible identification of
psychiatric disorders and initiation of appropriate treatment.
Many violent and/or homicidal acts are a result of psychiatric disorders turned outward into
aggressive acts of violence.
Stigmatization surrounding gender identity issues is strongly associated with suicidal
behavior.
The use of firearms is strongly associated with completed suicides.
There is a serious lack of available, accessible and timely services as well as inadequate
coordination among the agencies that encounter and intervene in the lives of young people at
risk.
Recommendations
Early, systematic identification and treatment are essential for children and youth at risk for
suicidal episodes.
Children and youth must have universal access to mental health care.
Appropriate training for professionals should be developed and required.
Existing services should be coordinated and consolidated with the addition of a centralized
information line and data collection and tracking system.
Serious efforts to control access to firearms among children and youth should be initiated.
Arizona's Child Fatality Review Team should be strongly encouraged to review
adolescent suicidal episodes and develop prevention and early intervention strategies.
SUPPORTING MATERIALS
The following flow chart visually represents factors that tend to increase or decrease the risk of
suicidal episodes. A suicidal episode is defined as an occurrence of suicidal ideation, threats, attempts
or completion or any combination of these factors (Pffeffer et al., 1991).
In addition, a hypothetical case study has been included to illustrate a possible scenario. Problems
included are those that are likely to be encountered within the various systems that frequently interact
with children and youth at risk. Points of contact with these systems are also highlighted with
suggested interventions.
ADOLESCENT SUICIDE RISK AND PREVENTION
RISK FACTORS PREVENTION FACTORS
TERTIARY PREVENTION
Obtain care after event
CASE STUDY
AN ADOLESCENT SUICIDE ATTEMPTER
A fourteen year old white male was brought to the emergency room by police following a suspicious
single car accident. He had borrowed his mother's car, run off the road, hit a tree and was treated for
a concussion and minor injuries. He was under the influence of alcohol at the time of the accident.
He was upset about his mother's nagging him about not going to school. He also appeared despon-dent
and depressed. He was admitted for a 72 hour evaluation and the Regional Behavioral Health
Authority (RBHA) was asked to assess his behavioral health needs.
This 14 year old male had been to the emergency room on various occasions for injuries sustained
during one prior auto accident and numerous fights. His mother indicated that drugs or alcohol were
involved on all occasions. The mother, a 30 year old single white female living in an urban area, was
mildly mentally retarded and could not remember the exact times or locations of the previous hospi-talizations.
She worked part-time cleaning houses. There was a 11 year old sister. The mother was
not married but both children had the same father. She reported that neither she nor the father had
completed high school. Both families, apparently, had some history of depression and suicidal
episodes. The father was presently incarcerated in the state prison for child molestation of his daugh-ter
and another neighborhood girl. Child Protective Services (CPS) was involved at the time of the
disclosure of molestation and the daughter had been briefly placed in foster care. She was returned to
her mother when the father was arrested and removed from the home.
The mother had communication difficulties but believed her son had become increasingly depressed
over the past six months and she suspected that he was involved with a local gang. She stated that
her
son is also mildly mentally retarded and is in special education classes at the public school. Addition-ally,
the boy had suffered from grand ma1 seizures since he was three years old. They have been
partially controlled by medication which he takes irregularly. The family receives medical care
through AHCCCS.
The boy has always done poorly in school but recently his attendance has been very irregular. The
principal discussed this with the mother on several occasions. She stated that she cannot control her
son and can't force him to go to school. He has been spending more and more time with friends and
recently his mother found a gun in his room. The police have been called for various neighborhood
incidents of fighting and, at one point, he threatened to kill his mother and his sister with a knife.
Charges were not pressed.
The young man stated that he hates school because others make fun of him because he is slow and
weird and the only place where he feels accepted is among his gang who are school dropouts. His
sister indicated to the emergency room staff that she has been worried about her brother for some
time. He once told her when he was drunk that he felt like dying.
SYSTEMS ISSUES
In the previous case study there are various points at which interventions could have occurred to
assist the youth and his family but did not or were not sufficient to ensure timely and appropriate
services.
This youth was identified at age three as having neurological problems manifested through grand ma1
seizures and poor fine motor coordination. Although he received medication for this condition, no
known referrals were provided at this time for neuropsychiatric or developmental disability (DD)
assessment. His mild mental retardation was not discovered until he was in second grade when he
was referred for behavior problems and testing.
Testing provided through the school resulted in a recommendation for placement in special education,
however, he was not placed until he was in 5th grade. By this time, his achievement had further
declined and his behavior problems had worsened. Because his medication was not effectively
monitored, he continued to experience seizures at school.
The special education teacher noticed signs of depression which she discussed with the mother. The
teacher suggested sources for assistance but the mother did not pursue them. The boy's acting out
behavior increased over the years as his achievement declined. By the time he reached the junior
high school level, his attendance was poor and school staff suspected gang involvement. Several
incidents involving the police resulted in brief detentions but no follow up behavioral health services.
The most recent incident led to emergency room treatment and the 72 hour evaluation through the
local Regional Behavioral Health Authority (RBHA). The evaluation revealed severe depression with
conduct disorder. Although the boy admitted to suicidal thoughts, he was not deemed actively
suicidal at discharge. A treatment plan was developed by the RBHA which included in-home therapy
and medication monitoring. Although he was placed on antidepressants, he did not take them
regularly, refused to attend the in-home therapy sessions, ran away on several occasions and had
several additional skirmishes with police.
Since this treatment was not successful, a staffing was held by the RBHA to address future planning.
Results of the staffing included recommendations for services through Developmental Disabilities in
cooperation with the RHBA for a therapeutic group home placement. This recommendation was the
result of escalating concerns about the boy's deteriorating mental and physical condition and
increased risk for suicide.
The RBHA and the Department of Developmental Disabilities disagreed over the child's primary
diagnosis which affected placement decisions and funding responsibilities. Additionally, in the most
recent school individual education plan (IEP), the school district recommended residential treatment
since they considered the child to be uncontrollable in his current setting. DDD considered the need
for intensive residential service to be totally related to behavioral health issues rather than seizures or
retardation.
The RBHA believed that a DD group home with wrap around behavioral health services was the most
appropriate intervention clinically and most cost effective since costs would be shared.
The Behavioral Health Services Medical Director was contacted by the school district due to Hodges v.
Bishop mandates and the child was placed in residential treatment.
The RBHA appealed this decision for clinical reasons. In addition, the full burden of funding was
their responsibility until the child became eligible for Title XIX behavioral health services.
POINTS OF INTERVENTION
In an ideal system, interventions would occur at the earliest point and comprehensive, preventive
services would be provided. The following list illustrates points of possible entry and treatment or
services that could have been accessed.
CRITICAL POINT POSSIBLE INTERVENTION
The mother was a teenager when
her child was born. She could have
been identified as high risk during her
pregnancy or at the birth of her child.
Her developmental delay could have
been discovered at this time.
Services for high-risk mothers such as
Healthy Families could have been provided.
If the developmental delay was discovered,
the mother may have been eligible for
services through Developmental Disabilities.
A pediatrician discovered the boy's seizure Referrals for neurological and
disorder when he was three years old. developmental assessments would have
been appropriate. If results indicated the
need, referrals to DDD or Behavioral Health
Services could have been made.
The boy entered school at age 5 or 6.
Mental deficiencies and continuing
medical problems might have been
discovered.
In second grade problems were identified
and recommendations were made for a
special education placement. Placement
did not occur until 3 years later.
The special education teacher noticed that
the boy seemed depressed and suggested
that the mother seek counseling. The
mother did not follow through.
The boy was involved in various minor
skirmishes with the police and briefly
detained.
The boy was brought to the emergency
room on several occasions for minor
injuries sustained in fights.
Appropriate remedial strategies or referrals
could have been initiated by the school
nurse or other staff upon initial screening.
Special education services could have been
implemented immediately.
When the mother did not follow the
teacher's suggestions, the teacher could
have discussed the case with the school
psychologist. Teacher or psychologist could
have met with the mother and suggested
other available resources.
These incidents could have resulted in
juvenile court intervention and court
ordered treatment could have occurred at
this time.
Emergency room staff should have made
referrals to have the youth evaluated.
Policies and Procedures
Every school district is required by law (A.R.S. 15-345) to have written chemical abuse (alcohol and
other drug use) policy and procedures. It is highly recommended that such policy and procedures be
broad and comprehensive to include identifying and assisting students or staff who are not only at
risk for chemical abuse but might also be at risk for suicidal behavior.
Technical Assistance, Training for School Districts, and the Development and Dissemination of
Prevention Curriculum
Arizona is fortunate to have available a wide variety of resources for technical assistance and training
regarding prevention. One of those resources is the Arizona Prevention Resource Center (APRC)
which is Arizona's central source for prevention information and materials. In addition to providing
materials for special target and high risk populations, the APRC can provide a network of trainers,
educators, and consultants, entitled "PeopleLinks," to provide effective training and technical assis-tance
to schools in developing, implementing, and evaluating their comprehensive school/community
prevention efforts. The Arizona Prevention Resource Center is a cooperative effort of four state
agencies: the Governor's Office of Drug Policy, the Arizona Department of Education, the Arizona
Department of Health Services, and Arizona State University, College of Extended Education. It is
recommended that school districts take advantage of these excellent services.
CONCLUSIONS AND RECOMMENDATIONS
Comprehensive programs that include primary, secondary and tertiary activities should be in
place in all schools in Arizona.
An integrated prevention curriculum should emphasize protective factors, resilience, positive
health and well-being.
Preservice training should be provided in all teacher education programs in the state.
All classroom teachers should be provided with adequate inservice training in the develop-ment
and use of integrated prevention curriculum.
A multidisciplinary child study team (CST) or crisis response team (CRT) should be
established in each school to implement assessment, intervention and referral procedures.
This team should collaborate with local mental health agencies.
Each school should establish guidelines for dealing with death or traumatic events in the
school or community. An inservice training for all faculty and staff should include training
in the policies and procedures for managing a crisis or traumatic event.
The chemical abuse policy and procedures that are required by law (ARS 15-345) should be
broad and comprehensive to include identifying and assisting students or staff who are not
only at risk for chemical abuse but might be at risk for suicidal behavior.
Support groups should be provided for students that have been identified as at-risk for self-defeating
behaviors.
REFERENCES
Public Health Service, Center for Disease Control. (1991a). Chronic disease and health
promotion: Youth risk behavior surveillance system. Washington, DC: U.S. Department of
Health and Human Services.
Public Health Service. (1991b). Healthy people 2000: National health promotion and disease
preventiun objectives-full report with commentary. Washington, DC: U.S. Department of
Health and Human Services.
Arizona Department of Health Services, Office of Planning and Health Status Monitoring. (1991).
Suicide mortality Arizona, 1980-1989. Phoenix, AZ: Author.
Arizona Department of Education, Special Programs Division, Comprehensive Health Unit. (1991).
Model policy and procedures: Alcohol and other drug prevention. Phoenix, AZ: Author.
Arizona Department of Education. (August, 1992). Chemical abuse prevention program
evaluation (CAPPE): Executive Summary. Phoenix, AZ: Author.
Shaffer, D., Garland, A. & Whittle, B. (1988). An evaluation of youth suicide prevention programs.
Unpublished report.
Shaffer, D., Garland, A., Vieland, V., Underwood, M. & Busner, C. (1991). The impact of
curriculum-based suicide prevention programs for teenagers. Journal of the American
Academy of Child & Adolescent Psychiaty, 30,588-596.
Shaffer, D., Vieland, V., Garland, A., Rojas, M. Underwood, M., & Busner, C. (1990). Adolescent
suicide attempters: Response to suicide prevention programs. Journal of the American
Medical Association, 264, 3151 -3155.
COMMUNITY BASED PROGRAMS SUBCOMMITTEE
COMMUNITY BASED PROGRAMS SUBCOMMITTEE REPORT
Assisting suicidal youth or teenagers in need of behavioral health services is not an easy task.
Traditional community-based counseling services are generally not utilized by the teenage
population. This approach tends to be geared toward the adult population and does not effectively
address the adolescent in crisis. In general, adolescents rarely seek help from a mental health
professional. According to Offer et al. (1991), the majority of distressed adolescents would be
willing to go to a school-based clinic, prefer to talk to friends and parents regarding emotional
problems, and find the help from both friends and parents beneficial. While nondisturbed
adolescents prefer to turn to their parents for help, disturbed adolescents usually turn to friends.
For those adolescents who did seek help from a behavioral health professional, Earls (1989) indicated
that only one quarter of adolescents in treatment reported their suicidal thoughts or attempts to the
clinic they attended. Of those adolescents who did report, it was done at either a school-based and/or
neighborhood-based clinic. Thus, utilizing new modalities to reach teenagers in a nonthreatening
manner becomes a key component in effectively addressing the behavioral health needs of this
population. If teenagers will not come to a traditional behavioral health setting, moving these services
to a nontraditional setting is vital. Locating such services in youth centers then becomes a viable
option.
Location, however, is not the only barrier to accessing services. Adolescents seeking services face
many other obstacles within the existing behavioral health system. Reducing the barriers or guiding
teens through them is therefore necessary to ensure that youth receive help.
Also, training for those who are likely to come into contact with suicidal youth is vital. Rotheram-
Borus (1989) suggested that those individuals who work with youth (teachers, recreation leaders, staff
at runaway shelters, ministers, etc.) should be able to identify and intervene with suicidal youth.
Consequently, gatekeeper training on basic behavioral health issues as well as suicide assessment is
necessary.
Another key component in reaching this population can be provided in two ways: utilizing a hotline
and peer counselor/helpers. Shaffer et al. (1988) suggested that hotlines and crisis services can be
beneficial with the adolescent population if the service is an identifiable service by teens in the
community, a 24-hour service, and advertised in the presence of the target group. Staffing a hotline
with "teen volunteers" can be helpful in reaching adolescents. Utilizing teens in suicide prevention
and intervention can be an important tool. Brent et. a1 (1988) reported that of those adolescents who
completed suicide, 83 percent had made a statement of their intent within the week of the suicide.
One-half had reported their intent to a friend or sibling only. Enlisting the help of friends and
siblings can improve the mechanism by which at risk youth are identified and referred for treatment.
Training natural and peer helpers can be an effective technique in identifying these young people.
Caplan (1989) suggested using natural helpers as a supportive network. Training for these helpers in
school and community settings is important.
Finally, after adolescents have sought help, it is important that they feel the services are relevant to
teen issues. Nelson et. al. (1988) stated that adolescents desire more relevancy in services provided.
Programs need to be geared toward the life experiences that youth find to be most meaningful.
This study recommended the availability of counseling and educational programs as well as a
supportive environment in the community for youth in crisis. Youth stressed the importance of
informal counseling and support. All groups surveyed reported the need to befriend and talk to
young people, to provide support in a loving way, and family support as key elements in an
intervention program. "Educational programs and intervention designs to prevent youth suicide
should address attitudes about communication and identify barriers to open communication among
adolescents themselves and their adult caregivers." (Nelson, 1988, p. 41)
RECOMMENDATIONS
One 24-hour statewide behavioral health hotline should be established for referral,
information and advocacy and should include a peer counseling component.
o Comprehensive, coordinated "gatekeeper" training should be available, especially regarding
adolescent depression, alcohol/drug assessment, suicide assessment and referrals.
o The availability of counseling, educational and meaningful recreational programs conducted
in a supportive community environment for youth in crisis should be increased. A team
approach coordinated at one site (one-stop shopping) is desirable.
Parental education regarding the significant danger of suicidal ideation, gestures and attempts
should be available. Parents should be provided with basic information on warning signs,
risk factors as well as information on how to access behavioral health services. This report
may serve to partially satisfy this need.
REFERENCES
Brent, D., Perper, J., Goldstein, C. Kolka, D., Allan, M., Aliman, C. & Zelenak, J. (1988). Risk
factors for adolescent suicide. Arch General Psychiatry 45, 581-588.
Caplan G. (1989). Recent developments in crisis intervention and the promotion of support service.
Journal of Primary Prevention, 10(1), 3-25.
Earls, F. (1989). Studying adolescent suicidal ideation and behavior in primary care settings.
Suicide and Life-Threatening Behavior, 19(1), 99-107.
Nelson, F. L., Farberow, N., & Litrnan, R. (1988). Youth suicide in California: A comparative study
of perceived causes and interventions. Community Mental Health Journal, 24 (I), 31-42.
Offer, D., Howard, K. I., Schonert, K. A. & Ostrov, E. (1991). To who do adolescents turn for help?
Differences between disturbed and nondisturbed adolescents. Journal of American Academy
of Child and Adolescent Psychiatry, 30 (4), 623-630.
Rotheram-Borus, M. J. (1991). Evaluation of suicide risk among youths in community settings.
Suicide and Life-Threatening Behavior, 19 (I), 108-119
Shaffer, D., Garland, A., Gould, M., Fisher, P., & Trautman, P. (1988). Preventing teenage suicide: a
critical review. Journal of American Academy of Child and Adolescent Psychiatry, 27( 6), 675-687.
Simmons, J. T. (1989). Prevention/intervention programs for suicidal adolescents. Report of the
Secretary's Task Force on Youth Suicide. Washington D.C.: U. S. Department of Health and
Human Services.
APPENDIX A
INTERVENTION PROCEDURES
INTERVENTION PROCEDURES
Suicide Crisis Response
Flagstaff Unified School District
A Crisis Response Team (CRT) will be established in each school in order to implement referral,
assessment, intervention or postvention procedures in situations related to suicidal risk or suicide
General Responsibilities of Crisis Response Team members:
1. Help faculty and staff understand symptoms and signals of potential suicidal behavior
and understand referral procedures.
2. Compile and keep current a confidential list of "at-risk" students; review and revise
list at periodic intervals.
Referral Response:
Only those members of the CRT who are trained as mental health professionals
(Counselors, school psychologists) and who have received suicide assessment/intervention
training may assess risk factors in order that appropriate procedures may be followed.
Referral Procedures:
1. A referral is made by a teacher, parent, staff member, friend, etc.
2. A member of the CRT qualified to make an assessment of risk factors will contact the
student.
3. The meeting with the student should result in a determination of whether the case
appears to be low risk, medium risk, or high risk. When there is a question on the part
of the CRT member or the supervisor of counseling and psychological services will
occur.
The following procedures should be followed depending upon the judgment made as to level of risk:
LOW RISK
Low Risk is characterized by communication of a double message; for example, a student
may say he/she has no suicidal thoughts, but his/her behavior contradicts this. At least some
low level objective data that suicide is a consideration ( such as journal entries). The student
may be mildly upset or mildly depressed; however, the depression is generally not chronic.
The student is undergoing or has recently gone through some crisis. There is a basic support
available to the student.
With any low-risk threat, contact the parent(s)/legal guardian(s). The CRT member should
call the parent(s)/legal guardiads) and inform them of the concerns and what is going on
with their child.
There is probably no need for the parent(s)/legal guardian(s) to come to school to pick up the
student(though parents(s)/legal guardian($ may wish to do so).
The CRT member will supply a list of outside referral sources. In addition to outside
referrals, the student may participate in an assistance program on campus.
The student's name is added to the list of at risk students maintained by the CRT.
MEDIUM RISK
Medium Risk is characterized by having a suicide plan which is not highly lethal; the means
to complete suicide plan are not immediately available; chronic depression is a factor, but the
student hasn't acted on it; implementing a suicide plan is not as imminent as with "high
suicide risk"; the student has an escalating preoccupation with suicide; the student expresses
ambivalence regarding suicide; the student may reach out for help.
The principal of the school is notified of the potential risk.
The parent(s)/legal guardian(s) is notified of the risk involved. The student is required to stay
with CRT member or other designated school personnel until the parent amved to have a
conference and to transport the student home and/or to treatment.
The CRT member will make a referral for outside professional assistance, supplying referral
sources. In addition to outside assistance, a student may participate in a student assistance
program on campus.
Follow-up is required. An appointment time and date will be set for the CRT member or a
designated person to see the student again. Additional follow-up may involve the school's
contacting the student's therapist, psychologist or psychiatrist directly. Help may be enlisted
from the student's teacher to monitor the situation.
Feedback about the disposition of the case is provided to the referral source.
The student's name is added to the list of at-risk students maintained by the CRT.
HIGH RISK
High Risk is characterized by the student having a suicide plan which is immediate and
highly lethal; is in imminent danger of self-harm; previous suicide attempts; appearance of
suffering from acute depression, a history of suicide/suicide attempts among family or
friends and feelings of helplessness and hopelessness or stated intent to die.
The principal of the school is notified of the potential risk for a student suicide.
The parent(s)/legal guardian(s) is notified of the risk involved. The student is required to stay
with the CRT member or other school personnel until the parent(s)/legal guardian(s) arrives
to have a conference and to transport the student to a treatment source.
The CRT member will supply a list of possible outside referral sources and assist the parent in
obtaining immediate intervention. If the parent(s)/legal guardian($ refuses to take the
student for outside professional help despite the school's effort to facilitate this, a report
should immediately be made to Child Protective Services. The student may also participate in
a student assistance program on campus.
When there is reason to believe the student is in immediate danger, the proper/or appropriate law
enforcement agency should be notified of the situation so that the student may receive appropriate
outside assessment and treatment. This may be done without the permission of parent(s)/legal
guardian(s), if they cannot be reached, under the following regulations (Title 34-99.36):
A. An educational agency or institution may disclose personally identifiable information
from the education records of a student to appropriate parties in connection with an
emergency if knowledge of the information is necessary to protect the health or safety
of the student or other individual.
B. The factors to be taken into account in determining whether personally identifiable
information from the education records of a student may be disclosed under this
section shall include the following:
1. The seriousness of the threat to the health or safety of the student or other
individuals,
2. The need for the information to meet the emergency,
3. Whether the parties to whom the information is disclosed are in a position to
deal with the emergency and
4. The extent to which time is of the essence in dealing with the emergency.
School personnel should never transport a student to a hospital or other care facility. The
police of parent(s)/legal guardian(s) are responsible for transporting.
Follow-up is required. The CRT member or designated person will set an appointment date
and time to see the student again when the student returns to school. Monitoring will occur to
determine if the student is receiving follow-up outside help. If this is not occurring, the
parent will be contacted again to be urged to obtain these services. Faculty help is monitoring
the situation will be solicited. Follow-up may involve the CRT member or designated person
contacting the student's therapist, psychologist or psychiatrist directly.
o Feedback about the disposition of the case is provided to the referral source, strong support
and praise for referring are recommended. Students who refer and/or intervene should be
assured that they have done the right thing in order for the person to receive help.
The student's name is added to the list of at-risk students maintained by the CRT.
Response to Off-Campus Attempts:
A CRT member will:
1. Call the parent(s)/legal guardian($ to verify the situation and determine probable
absence time.
2. Contact the student's teachers and request assignments, if appropriate.
3. Monitor the e student's friend, and/or follow-up on other students who may be
perceived to be risks.
4. Work with the parent(s)/legal guardian(s) and/or other professionals involved with
the student to share relevant information.
5. Upon the student's return, determine whether outside counseling is being provided
and by whom. Periodic contact and support should be provided by a CRT member or
designated person.
Response to Suicide:
1. An administrator calls to verify and obtain appropriate details. The same
administrator notified the district office.
2. The supervisor of counseling and psychological services will initiate a phone tree to
notify district members and request assistance as appropriate
3. Contact all administrators, counselors, the student's teachers, school psychologist and
nurse to inform them of the incident and request their presence at a faculty meeting.
4. Depending on time factors, a telephone tree is strongly suggested to notify faculty of
the suicide and request their presence at a faculty meeting.
5. Hold a faculty meeting to discuss procedures for the day and relay the facts about the
suicide. The following guidelines are suggested for teachers:
a. If there is likely to be a strong widespread response by many students, a
designated periods early in the day as possible should be encouraged for
classroom discussion rather than repeating discussions all day long.
b. Students should be allowed to talk about the suicide and their feelings.
Students who may appear to be having significant problems should be
escorted to a CRT member or counselor. Another student who appears to be
emotionally in control may do the escorting.
c. Class sessions through the remainder of the day should follow a relatively
normal routine, but with added flexibility. Attention spans are likely to be
shorter, students may still initiate questions or discussion related to the
suicide, and some students may show or demonstrate emotional upset to the
degree that a referral to the guidance department is in order.
d. In addition to allowing students to process feelings, teachers, particularly in
the period designated for discussion, may wish to share the following ideas
with their students:
While it is extremely regrettable that a young person has chose suicide,
students should think about the positive in their own lives and take
care of themselves.
o Referrals to the counseling department should be an option for
students feeling particularly troubled.
Help students understand that no single factor causes a suicide.
There is always more than one problem, usually of an ongoing
nature.
No one person can be responsible for the suicide death of another and
that even highly trained professionals cannot always predict it.
If a friend threatens suicide, teachers should be sure that the friend is
referred to a professional helper. Students should know it's okay to
break a confidence if it means it might save a life.
If a staff meeting is not possible, disseminate information about the suicide to all teachers and
inform them of what procedures to follow.
Call the district supervisor of counseling and psychological services, inform of theincident,
and, if needed, request the support of a district team to come to the building to work with
school personnel and students.
Contact the victim's parent(s)/legal guardian(s) to offer assistance and determine additional
action.
Continue with a normal school schedule, excusing students to attend the services.
Designate one school staff member to be the media spokesperson. Ask all other staff to refer
any media contacts to the designated spokesperson. Statements to the media should be
limited so as not to "dramatize" the occurrence, which could increase chances of "imitations".
Statements expressing regret and that the school has a plan to offer intervention and support are
probably sufficient. No personal statements about the victim or hidher family should be given.
Students who are possibly at risk for imitating the event should be contacted to assess how
they are doing.
Provide an opportunity through individual contacts or small groups for the victim's circle of
friends to discuss their feelings.
Adult support groups should be made available by the counseling department asappropriate
as soon as possible after the occurrence. Meetings such as these help to dispel feelings of
helplessness and frustration.
Teachers should be made aware of symptoms/signals and should be encouraged to refer
students who may be in need of help.
In Case of an Attempted or Completed On-Campus Suicide:
1. Notify an administrator immediately.
2. Notify district office and all CRT members immediately.
3. If an attempt, the nurse and an administrator will determine if the situation requires
immediate medical attention. If so:
a. The administrator will immediately notify the police and call for an
ambulance.
b. The parent(s)/guardian(s) should be notified immediately.
c. Have all CRT members available to deal with other students involved. Try to
keep students and faculty members away from the immediate crisis area.
Isolate any witnesses and/or friends with help from team members.
d. Notify the district office and supervisor of counseling and psychological
services for immediate assistance.
e. Refer all requests from the media to the district office. Make no comment.
Do not release information until after the crisis is over.
Arizona Department of Education, Comprehensive Health Unit (1991). Model Policy and
Procedures fur School District Alcohol and Other Drug Prevention Programs, pp. 23-28.